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Improving
Quality of Care
in India’s
Family Welfare
Programme
THE CHALLENGE AHEAD
EDITORS
Michael A. Koenig
o
M. E. Khan
Population Council
T -
PopuIationCouncil
The Population Council is an international, nonprofit, nongovernmental
institution that seeks to improve the wellbeing and reproductive health of
current and future generations around the world and to help achieve a humane,
equitable, and sustainable balance between people and resources. The Council
conducts biomedical, social science, and public health research and helps build
research capacities in developing countries. Established in 1952, the Council is
In memory of Professor George B. Simmons (1940-1990),
who combined a love for India
with an appreciation of
the power of organized interventions
to improve human welfare
governed by an international board of trustees. Its New York headquarters
supports a global network of regional and country offices.
Population Council
One Dag Hammarskjold Plaza
New York, NY 10017 USA
www.popcouncil.org
Library of Congress Cataloging-in-Publication Data
I
Improving quality of care in India's family welfare programme : the challenge
ahead I Michael A. Koenig, M.E. Khan.
p. cm.
Includes bibliographical references.
ISBN 0-87834-099-8 (pbk. : alk. paper)
1. Family policy—India. I. Koenig, Michael Alan. II. Khan, M. E.
III. Population Council.
HV700.I4 146 1999
362.82'0954—dc21
99-16481
CIP
Cover design by Burstein/Max Associates Inc.
Cover pattern adapted from a photograph by Sanjay K. Singh.
© 1999 by The Population Council, Inc. All rights reserved.
Printed in the United States of America
-
J
Contents
Tables and Figures
ix
Foreword
Ruth Simmons
xiii
Acknowledgments
xv
1
1
Introduction
Michael A. Koenig
Part I. Client Perspectives on the Quality of Care
2
3
4
'I
5
6
7
i
I
i
Women's Perceptions of the Quality of
Family Welfare Services in Four Indian States
T. K. Roy & Ravi K. Verma
19
The Quality of Family Welfare Services in
Rural Maharashtra: Insights from a Client Survey
Nimtala Murthy
33
The Quality and Coverage of
Family Planning Services in Uttar Pradesh:
Client Perspectives
M. E. Khan, R. B. Gupta, & Bella C. Patel
49
Rural Women's Experiences with
Family Welfare Services in Tamil Nadu
T. K. Sundari Ravindran
70
Provider-Client Interactions in Primary Health Care:
A Case Study from Madhya Pradesh
Sandhya Barge & Lakshmi Ramachandar
92
Women's Perspectives on the Quality of
General and Reproductive Health Care:
Evidence from Rural Maharashtra
Manisha Gupte, Sunita Bandewar, &Henilata Pisal
117
1
Part IL Provider Perspectives on the Quality of Care
8
The Quality of Reproductive
Health Care in Gujarat: Perspectives of
Female Health Workers and Their Clients
Leela Visaria
143
1
I
Contents
viii
Assessing the Quality of Family Planning
Service Providers in Four Indian States
Ravi K. Verma & T. K. Roy
169
10 Constraints to the Quality of
Primary Health Services in Rural Karnataka
Jagdish C. Bhatia
183
9
11 Barriers to the Quality of Care:
The Experience of Auxiliary
Nurse-Midwives in Rural Maharashtra
Aditi Iyer & Amar Jesani
12 The Quality of Family Planning Services in
Uttar Pradesh from the Perspective of Service Providers
M. E. Khan, Bella C. Patel, & R. B. Gupta
210
14 The Quality of Care in Sterilization Camps:
Evidence from Gujarat
Dileep Mavalankar & Bliarti Sharma
15 The Quality of Care in the
Sterilization Camps of Uttar Pradesh
TABLES
2.1
Contact between clients and government service providers:
Four Indian states, 1994
273
Choice of contraceptive methods: Four Indian states, 1994
24
2.3
Information given to clients: Four Indian states, 1994
25
2.4
Interpersonal relations with service providers as perceived
by women in the villages: Four Indian states, 1994
27
2.5
Interpersonal relations with service providers as perceived
by women during exit interviews: Four Indian states, 1994
28
2.6
Appropriate constellation of services: Four Indian states, 1994
29
3.1
Coverage of family welfare services, by clients' background
characteristics: Ahmednagar District, Maharashtra, 1994
37
3.2
Quality of service delivery, by clients' background
characteristics: Ahmednagar District, Maharashtra, 1994
39
3.3
Selected indicators of the technical quality of
family welfare services: Ahmednagar District, Maharashtra, 1994
41
3.4
Technical quality of MCH and family planning services,
by clients' background characteristics:
Ahmednagar District, Maharashtra, 1994
42
3.5
Sources of MCH and family planning services,
by village type: Ahmednagar District, Maharashtra, 1994
43
3.6
Client satisfaction with government and private services:
Ahmednagar District, Maharashtra, 1994
44
3.7
Satisfaction with government services,
by clients' background characteristics:
Ahmednagar District, Maharashtra, 1994
4b
4.1
Availability of family welfare facilities at
the subcenter level: Rural Uttar Pradesh, 1993-94
53
4.2
Clients' contact with the Family Welfare Programme
during the three months prior to the interview:
Rural Uttar Pradesh, 1993-94
54
Findings from studies on clients' contact with ANMs
and other health workers to discuss family planning:
Rural Uttar Pradesh, 1971-95
55
Percentage of women receiving outreach services
during the three months prior to the interview,
classified by workers' sex: Rural Uttar Pradesh, 1993-94
56
4.5
Percentage of women receiving outreach services
during the three months prior to the interview,
classified by client characteristics: Rural Uttar Pradesh, 1993-94
58
4.6
Purpose of health worker's last visit, as perceived by women
receiving outreach services during the three months
prior to the interview: Rural Uttar Pradesh, 1993-94
59
293
314
John W. Townsend, M. E. Khan, & R. B. Gupta
Part IV. Improving Quality of Care: A Change in Focus
16 The Effects of Service Quality on IUD
Continuation Among Women in Rural Gujarat
Daxa Patel, Anil Patel, & Ambrish Mehta
333
17 Developing an Alternative System of Monitoring
Indicators for the Family Welfare Programme
Jay Satia & Sangeeta Subramanian Sokhi
346
Contributors
369
23
2.2
238
Part III. Quality-of-Care Issues with Sterilization Services
13 The Quality of Services at Laparoscopic
Sterilization Camps in Madhya Pradesh
LaJishmi Rarnachandar & Sandhya Barge
Tables and Figures
4.3
4.4
x
4.7
4.8
4.9
4.10
4.11
Tables and Figures
Quality of information and counseling given to prospective
clients about specific methods: Rural Uttar Pradesh, 1993-94
62
Quality of client-provider interactions during last visit:
Rural Uttar Pradesh, 1993-94
63
Percentage of sterilized women and IUD acceptors
willing to recommend the method to others:
Rural Uttar Pradesh, 1993-94
4.12
Postacceptance follow-up and incidence of complications:
Rural Uttar Pradesh, 1993-94
6.1
Activities in two PHCs during four days of observation
(two days at each PHC): Vidisha District, Madhya Pradesh, 1994
6.2
Commuting and work schedules of six ANMs:
Vidisha District, Madhya Pradesh, 1994
7.1
7.2
Importance of indicators of quality of care in
four health-care-seeking situations:
Six villages of Pune District, Maharashstra, 1994-96
Choice of provider in nine health-care-seeking situations:
Six villages of Pune District, Maharashtra, 1994-96
8.1
Demographic and socioeconomic profile of ANMs:
Four rural districts of Gujarat, 1989-90
8.2
Logistic support received by ANMs:
Four rural districts of Gujarat, 1989-90
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
Indicators of the availability of IUDs and
oral contraceptives from ANMs:
Four rural districts of Gujarat, 1989-90
Average number of family planning clients per ANM
reported for the year preceding survey, by method accepted:
Four rural districts of Gujarat, 1989-90
ANMs' ranking of their tasks according to the priorities
of their supervisors and their own priorities:
Bharuch and Panchmahals Districts, Gujarat, 1989-90
Contact of respondent households with
health workers and utilization of health services:
Four rural districts of Gujarat, 1989-90
Contact of sterilized women with health workers
and services received: Four rural districts of Gujarat, 1989-90
Profile of women sterilized during 1989-90:
Bharuch and Panchmahals Districts, Gujarat
(based on 1991 retrospective survey)
Care received at the time of sterilization
by women sterilized in 1989-90: Bharuch and
Panchmahals Districts, Gujarat (based on 1991 retrospective survey)
Poststerilization follow-up care received
by women and complications experienced:
Bharuch and Panchmahals Districts, Gujarat, 1989-90
(based on 1991 retrospective survey)
8.11
Quality of care provided to ever-users of IUDs,
as reported by users: Bharuch and Panchmahals Districts,
Gujarat, 1989-90 (based on 1991 retrospective survey)
9.1
9.2
Selected characteristics of ANMs: Four Indian states, 1994
IM
171
Populations served and types of facilities and support
at 72 PHCs: Four Indian states, 1994
172
9.3
Information given to oral contraceptive clients
during initial meeting: Four Indian states, 1994
9.4
9.5
Contraceptive method choice: Four Indian states, 1994
9.6
9.7
9.8
10.1
Mechanisms for follow-up: Four Indian states, 1994
61
Percentage of clients reporting that workers insisted
upon a particular method: Rural Uttar Pradesh, 1993-94
Examinations and tests received by tubectomy and
IUD acceptors prior to acceptance: Rural Uttar Pradesh, 1993-94
Tables and Figures
64
64
Technical knowledge and competence of ANMs:
Four Indian states, 1994
173
175
Supervisory support and job commitment: Four Indian states, 1994
176
178
179
180
Time utilization pattern of ANMs at a rural PHC:
Kolar District, Karnataka, 1994-95
198
10.2
Time utilization pattern of an LHV at a rural PHC:
Kolar District, Karnataka, 1994-95
198
10.3
Observed activities of medical officers at a rural PHC:
Kolar District, Karnataka, 1994-95
Profile of ANMs: Rural Maharashtra, 1990-91
146
11.1
11.2
11.3
149
65
94
114
123
128
ANMs' current economic role: Rural Maharashtra, 1990-91
Time utilization of ANMs on the last working day
prior to interview: Rural Maharashtra, 1990-91
223
11.4
Provision of government accommodation:
Rural Maharashtra, 1990-91
224
11.5
Subcenter facilities, essential furniture, and basic equipment:
Rural Maharashtra, 1990-91
227
11.6
Strategies and material incentives employed by ANMs to motivate
women to use family planning methods: Rural Maharashtra, 1990-91
231
11.7
ANMs' views on the effect of removing family planning targets:
Rural Maharashtra, 1990-91
233
11.8
ANMs' views on the hypothesized effects on health work
of the removal of targets: Rural Maharashtra, 1990-91
12.1
12.2
Study coverage: Sitapur District, Uttar Pradesh, 1995
233
239
Number of villages and combined populations
in areas assigned to ANMs: Sitapur District, Uttar Pradesh, 1995
242
12.3
Supplies of medicines at selected subcenters:
Sitapur District, Uttar Pradesh, 1995
245
12.4
Availability of equipment and medical supplies
at selected subcenters: Sitapur District, Uttar Pradesh, 1995
246
12.5
Percentages of sterilization and IUD targets met
by 54 ANMs: Sitapur District, Uttar Pradesh, 1994-95
260
13.1
Observed laparoscopic camps and cases:
Vidisha District, Madhya Pradesh, 1995
15 1
15.2
Chronology of sterilization camps in India
275
315
Clients' reports of problems with sterilization:
Uttar Pradesh, National Family Health Survey, 1992-93
320
154
155
158
160
161
162
|99
215
217
151
152
Measure of constellation of services: Four Indian states, 1994
xii
15.3
15.4
16.1
16.2
16.3
16.4
17.1
17.2
Tables and Figures
Infrastructure and equipment, by level of facility:
Three camps in Sitapur District, Uttar Pradesh, 1995
Mandated versus observed operative procedures
for sterilization: Three camps in Sitapur District, Uttar Pradesh, 1995
Selected characteristics of women accepting IUDs
during 1987-90 and 1991-93: Rural Gujarat
Complaints of discharge, bleeding, or pain among
Phase 1 and 2 IUD acceptors: Rural Gujarat
Problems reported within six months of IUD insertion among
Phase 1 and 2 IUD acceptors: Rural Gujarat
Reasons for IUD removal among
Phase 1 and 2 IUD acceptors: Rural Gujarat
Needed changes in relative emphasis:
Monitoring indicators for the Family Welfare Programme
Dimensions of quality of care for reproductive health services
323
324
339
340
341
341
359
363
figures
14.1
14.2
16.1
16.2
Acceptors of male and female sterilization: India, 1956-92
Acceptors of tubectomy: Gujarat, 1993-94
IUD continuation rates in Phases 1 and 2,
taking into consideration removals for all reasons: Rural Gujarat
IUD continuation rates in Phases 1 and 2,
taking into consideration removals due only
to IUD-related problems: Rural Gujarat
Foreword
294
296
342
343
This volume is a great step forward in the long history of publica
tions on family planning in India. Here, finally, we have detailed em
pirical data and analysis of the various dimensions of quality of care
from different regions in the country on such subjects as: women's
perceptions of the care they receive; observations of provider-client
interactions; barriers to quality of service delivery; existing inter
regional variations; contraceptive choice and interpersonal relations;
technical quality of care, especially in regard to sterilization camps;
and the effect of the target system on the work style of outreach staff.
All elements of the quality-of-care framework elaborated by Judith
Bruce are well documented and their relationships to broader pro
gram constraints are clearly identified. Although the picture that
emerges is by no means uniform, the overall impression one receives
from this volume is of the massive change that is needed before the
Indian program can meet the reproductive and quality-of-care objec
tives in recent policy statements and address the needs of rural people.
Observers of family planning in India have been familiar with
many of the conditions described in the volume, some of which have
also been discussed in previous publications, from both within and
outside of India. However, we have not yet seen analysis of quality of
care that is as detailed and comprehensive as what appears here. In
addition, no previous publications have paid as much sustained atten
tion to the realities of program implementation and to the perspectives
of local people. The volume also has special significance because it as
sembles research undertaken by Indian scholars and professionals
whose work is often not readily accessible to an international audience.
The data presented here provide an essential baseline diagnosis
for policymakers and program managers interested in advancing the
xiv
Fore word
Indian program's transition to emphasizing quality of care. Given the
current reorientation toward a target-free approach to family plan
ning services in India, this is indeed an opportune moment for this
volume to appear. One cannot help but wonder, however, why such
detailed documentation and analysis of the status of quality of care
in the Indian program was not published earlier. A picture this clear
calls for action, and, as this book documents so clearly, action to re
orient the program has been needed for a long time.
The book is also extremely relevant for researchers interested in
the study of quality of care and the interactions between program
representatives and local people. The value of both quantitative and
qualitative data in such research is amply demonstrated. With this
inventory in hand, researchers can now move forward in the contin
ued study of quality of care, and especially in researching ways in
which these findings can lead to improvements in the day-to-day pro
vision of family planning services.
Ruth Simmons
Professor
Department of Health Behavior and Education
School of Public Health
University of Michigan
Acknowledgments
This volume owes its existence to many individuals and institutions.
We are indebted to the United States Agency for International Devel
opment, the Population Council, and the Ford Foundation for cofund
ing the original 1994 Bangalore workshop, "The Quality of Services
in the Indian Family Welfare Programme," on which much of this
volume is based. We are grateful to William Goldman, previously
Chief of the Office of Population, Health, and Nutrition at USAID,
New Delhi, and to John Townsend, previously Director of the Popu
lation Council's Asia and Near East Operations Research Project, for
providing financial support. We wish to particularly recognize the
Ford Foundation and David Arnold, previously the Representative
for India, Nepal, and Sri Lanka, who understood early on the impor
tance of this issue, and made publication of the volume possible
through grants supporting Michael Koenig's time, as well as edito
rial and publication expenses.
A number of individuals have made key contributions at vari
ous stages of work on this volume. We are especially grateful to
Sandra Ward, whose adeptness at transcontinental technical editing
succeeded in melding a set of highly disparate papers into a com
mon format and style, while retaining and often sharpening the mean
ing and intent of individual contributions. We also recognize the con
tributions of Deepika Ganju, who invigorated the process of chapter
revisions at a time when the project was flagging. We are also grate
ful to Nance Cunningham of Johns Hopkins University and Jared
Stamm of the Population Council, for their careful reading and edit
ing in the final stages of work on the volume, and to Ann Extross and
Renuka Agarwala of the Ford Foundation, New Delhi, and V. L.
Thomas of the Population Council for their assistance with the prepa-
2
Introduction
These achievements notwithstanding, it is difficult to escape the
conclusion that the Indian family planning program remains charac
terized by considerable unfilled potential and promise. Its modest
progress stands in marked contrast to the progress of a number of
neighboring family planning programs in Asia—most notably
Bangladesh, Indonesia, and Thailand—which despite having launched
their programs much later, have achieved considerable success in rais
ing levels of contraceptive use. Nowhere is this disparity more appar
ent than in the large and populous northern states, which are home to
more than 400 million people, more than 40 percent of India's total
population.1 The reasons for the limited success of the Indian program
extend far beyond the service delivery program itself. They encom
pass a host of other social, cultural, and economic factors—including
low levels of female and overall educational attainment, continuing
high mortality, low status of women, and extreme poverty—which
influence the demand for fertility limitation (Cassen 1978; Satia and
Jejeebhoy 1991). In recent years, however, there has been a growing
consensus among policymakers, researchers, and informed observ
ers that the program itself—as reflected in its priorities, emphasis, and
the implementation of services—must be accorded primary responsi
bility for the limited success of family planning in much of India.
Much has already been written about the Indian family plan
ning program. As one of the most ambitious organized efforts to in
fluence human fertility in a country of key demographic importance,
the program has been extensively documented and critiqued over the
last several decades. Much of this research has focused on the analy
sis of population and family planning policies within India. One set
of studies has described the historical evolution of population and
family planning policies in India since the program's inception in the
1950s (Narayana and Kantner 1992; Visaria and Chari 1998). A sec
ond constellation of studies has focused upon the impact of the po
litically turbulent 1976-77 Emergency Period—when compulsory ster
ilization was introduced in many parts of India—in terms of its
immediate and subsequent political and programmatic impact (Basu
1985; Cassen 1978; Gwatkin 1979; Kocher 1980; Pai Panandiker and
Umashankar 1994). Other more recent work has sought to describe
the major shifts in population and reproductive health policies that
have been taking place in India following the 1994 International Con
Michael A. Koenig
ference on Population and Development (Measham and Heaver 1996;
Visaria and Chari 1998; Visaria, Jejeebhoy, and Merrick 1997).
A second focus of research on the Indian family planning pro
gram has been its organization and resource inputs, in terms of struc
ture (Misra et al. 1982; Narayana and Kantner 1992; Simmons and
Ashraf 1978), facilities, equipment, and staffing (ICMR 1991; Satia and
Giridhar 1991; Soni 1983), and financing and resource allocation
(Berman and Khan 1993; World Bank 1995). Another set of studies
has focused on program outputs, as reflected by contraceptive preva
lence, acceptance levels for specific methods, and utilization of other
maternal and child health (MCH) services (UPS 1995; Satia and
Jejeebhoy 1991; Soni 1983).
In view of this extensive body of research on the Indian family
planning program, it is therefore surprising how little is actually
known about how the program is implemented at the field level—at
the interface between the program and its clients. Although frequent
references are made to the serious gaps in quality of family planning
services provided by the Indian public sector (Conly and Camp 1992),
empirical evidence on this issue remains limited, unsystematic in na
ture, and largely unpublished and inaccessible to the research and
policy communities.2 Little has been published on how existing poli
cies and program inputs translate into implementation practices at
the field level. Even less is known about the nature and content of
interactions that take place between family planning program per
sonnel and current or potential clients on a day-to-day basis. Limited
evidence also exists on how service providers themselves define, pri
oritize, and carry out their mandated responsibilities, as well as the
barriers they face to providing high-quality services. And perhaps
most importantly, little is known about the perspectives, perceptions,
and direct experiences of Indian women themselves—both among
users and especially among nonusers—in terms of the quality and
adequacy of services they have received through the public-sector
family planning program. Finally, we know remarkably little about
how current standards of care inhibit or deter women from seeking
or continuing to utilize family planning and other services offered
through the Family Welfare Programme.
Recognizing these significant information gaps, the Population
Council organized a three-day workshop entitled "The Quality of
xvi
I
Acknowledgments
ration of the manuscript. Shireen Jejeebhoy, Leela Visaria, and Pravin
Visaria—friends and colleagues—read the initial draft of the intro
duction and provided timely reassurance that it was not badly off
track. The inputs from the two technical reviewers—John Kantner and
Ruth Simmons—provided useful critiques and reinforced our belief
that the volume made new and important contributions to an area
that has already received extensive study. We deeply appreciate the
contribution of Ethel Churchill of the Population Council to the pub
lication of this volume, for her continued strong interest in the vol
ume and her efforts to ensure wide dissemination of the volume both
within and outside of India.
We would also be remiss without expressing our gratitude to
the individual authors themselves, for going the "extra mile" in their
willingness to, in many cases, make multiple revisions of their pa
pers, and for ensuring that the final product was of a uniformly high
standard. Finally, we wish to recognize the support and stimulation
we have received from our respective families—Gillian, Matthew, and
Leah in Baltimore and Nusrut, Rabia, and Irfan in Baroda—who give
meaning to all of our work.
May 1999
Michael a. Koenig
M. E. Khan
1
Introduction
MICHAEL A. KOENIG
In 1952, India became the first developing country to establish a na
tional family planning program to address the issues of high fertility
and rapid population growth. In the more than four decades of its
existence, the Indian family planning program has been both highly
visible and the subject of intensive international interest and analy
sis. A primary explanation for this interest lies in India's global de
mographic significance. With a population approaching one billion
people, India accounts for almost one-sixth of the world's people. It
is estimated that by the middle of the next century, it will surpass
China as the world's most populous country.
Over the past four decades, significant growth and expansion of
the Indian family planning program have been evident. Starting from
virtually no infrastructure, the Indian program has grown to encom
pass over 150,000 primary health centers (PHCs) and subcenters, em
ploying more than 300,000 family planning personnel. This network
of services now extends to almost the entirety of India's people, threefourths of whom continue to reside in 600,000 often small and iso
lated communities. As evidenced by the most recent National Fam
ily Health Survey in India, knowledge of family planning among
reproductive-aged women is by now almost universal, and by the
early 1990s 41 percent of couples were currently using a method of
contraception (UPS 1995). Largely as a result, total fertility rates in
India have declined significantly over the last several decades, from
6.0 births in the 1950s to 3.4 births by the early 1990s. In addition, the
program has gradually expanded the range of services it offers to in
clude immunization, antenatal and delivery care, preventive and cura
tive health care, and, most recently, reproductive health care.
4
Michael A. Koenig
Introduction
Services in the Indian Family Welfare Programme" in Bangalore, In
dia, in May 1995, with support from the Ford Foundation and the
United States Agency for International Development. The workshop
brought together for the first time a diverse mix of policymakers, so
cial scientists, public health physicians, members of nongovernmen
tal organizations, and women's health activists to consider a coun
trywide perspective on the nature and quality of services provided
by the Indian family planning program. The collective picture that
emerged from the workshop provided an unprecedented ground-level
view of quality of care within the national program.3
No a priori attempt was made to define the dimension of qual
ity of care for workshop participants. Yet, as is evident from the
present volume, the focus of almost all of the studies is upon what
Donabedian has defined as the two critical elements of quality of care:
technical care and the interpersonal relationship between the practi
tioner and the client (Donabedian 1988). Many of the studies presented
also draw significantly upon the six elements of the quality-of-care
framework developed by Judith Bruce specifically for family plan
ning services (Bruce 1990).
The issue of quality of care was evaluated from multiple service
delivery levels—clinical services, PHCs, and outreach services—and
from multiple perspectives—individual women clients, community
outreach workers, medical personnel, and program managers. The
studies also employed a range of innovative research methodologies
to examine the issue of quality of care—including respondent and
workers surveys, client exit interviews, client-provider interaction ob
servations, focus-group discussions with both clients and providers,
and situation analysis. The diversity of approaches and methods gen
erated an unprecedented wealth of information on a wide range of
quality dimensions of the Indian program, including service access
and availability, information provided to clients, choice of methods,
interpersonal relations, technical competence, and follow-up and con
tinuity of care.
The present volume consists primarily of selected edited papers
from the Bangalore workshop, augmented by several additional stud
ies that were unavailable at the time of the original workshop. The
volume is organized into four main sections: (1) evidence from com
munity-based surveys and in-depth, qualitative research on clients;
14
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SKIS *
■■
.
5
(2) qualitative and quantitative studies of service provider perspec
tives on quality of care; (3) studies of clinical quality of care provided
in sterilization camps; and (4) programmatic evidence and policy is
sues associated with improving the quality of care.
In Chapter 2, T. K. Roy and Ravi K. Verma present findings from
their four-state study of quality of care in India, which included two
North (Bihar and West Bengal) and two South (Karnataka and Tamil
Nadu) Indian states. The study highlights the significant differences
(frequency of outreach visits, availability of physicians and medicines)
that characterize the Indian program, with the program in southern
states performing consistently higher in most areas. The study also
outlines quality-of-care concerns that appear to cut across almost all
programs—including dominant emphasis on sterilization and limited
information to clients on method use and side effects—and suggests
that the contraceptive choice provided to clients might be no wider,
and possibly even more limited, in the South Indian states, which have
high contraceptive prevalence.
In Chapter 3, Nirmala Murthy provides further evidence on cov
erage levels and perceived quality of public sector health and family
planning services, based upon detailed analysis of a sample survey
of women in the western Indian state of Maharashtra. The study high
lights the important role of geography in determining service access,
and finds that respondents residing in more remote communities are
less likely to have been visited by health workers, to have been vis
ited for adequate lengths of time, and to have received other MCH
services. The study also finds that workers may make selective deci
sions about providing contraceptive choice and information, with
women residing in more remote communities and poorer women sub
stantially less likely to have been informed about spacing methods of
contraception and method side effects.
In Chapter 4, M. E. Khan, R. B. Gupta, and Bella C. Patel present
the results from a large statewide survey of Uttar Pradesh in North
India. Their results underscore an important but frequently over
looked point: In difficult settings such as North India, basic access to
services by clients may often take precedence over quality concerns.
The authors found that only a small minority of respondents reported
any recent contact with family planning outreach staff, a level that
does not appear to have changed appreciably over the last two dec-
6
Introduction
ades in Uttar Pradesh. This minority of women who were visited,
however, expressed generally favorable views about the services they
received and the further interaction they had with program staff. The
study also found that significant numbers of acceptors of steriliza
tion and the intrauterine device (IUD) were unwilling to recommend
these methods to others, perhaps not surprising in view of the sig
nificant rates of reported method-related complications and low lev
els of follow-up by program staff after acceptance.
The final three chapters in Part I consider client perspectives on
quality of care, based on qualitative evidence. In Chapter 5, T. K.
Sundari Ravindran takes an in-depth look at rural women's experi
ences with the family planning program in Tamil Nadu, widely re
garded as a demographic success story, with fertility having reached
replacement levels. A series of case studies highlights important gaps
in such service dimensions as voluntary and informed contraceptive
choice and the technical standards and competence of program per
sonnel; it also points to widespread corruption among program staff
and frequent insensitivity to clients' needs. Despite Tamil Nadu's
reputation as having a strong and well-run family planning program,
the results of this study indicate that considerable scope exists for
improving the overall quality and client orientation of public sector
services.
In Chapter 6, Sandhya Barge and Lakshmi Ramachandar present
findings from an in-depth observational study of service provider
client relations in a rural area of the northern state of Madhya Pradesh.
The study provides considerable insight into the nature and impor
tance of interactions between female paramedical staff and women
clients. Case studies highlight the systemic problems of access and
quality that characterize outreach services in this challenging service
environment: nonresidence and abbreviated working hours of female
paramedical staff; irregular and infrequent outreach visits, especially
to more remote communities; chronic shortages of equipment and
supplies; and an overriding programmatic emphasis on sterilization.
Yet, despite these systemic problems, the overall picture presented is
one of reasonable quality services at the level of the PHC, and gener
ally positive interpersonal relations between female paramedical staff
and their clients.
In Chapter 7, Manisha Gupte, Sunita Bandewar, and Hemlata
Pisal explore women's perspectives on quality of health and repro-
Michael A. Koenig
7
ductive health care through an innovative ranking approach carried
out as part of focus group interviews with a small sample of women
in rural Maharashtra. Their study makes the important point that there
may be no single fixed perspective on quality of care. Women instead
appear to be highly pragmatic, prioritizing quality of care dimensions
differently according to specific health care needs and marital situa
tions. The authors find that the aspect of service delivery to which
women give priority for general health care is the doctor's full atten
tion. For delivery care, client priorities are availability of support staff
to clean up and convenient location and timing. For abortion within
marriage, women give priority to the absence of a requirement for
the husband's permission. For abortion outside of marriage, the as
surance of confidentiality is ranked highest. For abortion services in
general, women appear willing to trade safety and quality of care con
siderations for assured confidentiality, which helps explain why the
private sector is the preferred source for this service.
Part II presents results from quantitative and qualitative studies
of the service providers' perspectives on quality of care. In Chapter
8, Leela Visaria presents findings from surveys with female paramedi
cal staff, their client populations, and contraceptive acceptors in the
western state of Gujarat. Visaria finds that the Gujarat program has
the capacity to provide high-quality services: a high proportion of
staff resident in the communities in which they work; few shortages
of key equipment and supplies; and high levels of staff training and
technical competence, outreach and follow-up, and client satisfaction.
At the same time, her study highlights the potential drawbacks of a
system characterized by undue emphasis on method-specific contra
ceptive targets. One important consequence is significant discordance
in terms of program priorities, with supervisors assigning highest pri
ority to family planning, in contrast to outreach workers who accord
highest priority to maternal health needs. The study delineates other
detrimental consequences of the target emphasis, including limited
contraceptive choices offered to most long-term method acceptors,
the entry of non-health personnel into the contraceptive recruitment
process, and significant overreporting of acceptance levels for most
temporary contraceptive methods.
In Chapter 9, Ravi K. Verma and T. K. Roy present findings from
a survey of female paramedical workers in their four-state study of
thp Indian familv nlannincr nrncrrqm Thoir Fir»Jir»rrr' bJrrkl
I
I-
■
‘i
I
I
8
Michael A. Koenig
Introduction
ber of service areas where considerable scope exists for improvement
in quality of care in contraceptive information and choice, technical
competence, and follow-up. They found, for example, that in most of
the states, only a minority of workers discussed clients' reproductive
goals, how family planning methods are used, or their potential side
effects. In all four states, workers reported choosing the contracep
tive method for their clients in a vast majority of cases. The study
provides considerable insight into program priorities as viewed by
the workers. In all states (but especially in Tamil Nadu), workers re
ported considerable pressure to achieve their assigned sterilization
acceptor targets. They were under significant but somewhat less pres
sure to achieve their assigned targets for spacing methods, and rela
tively little pressure to provide follow-up care to current users. The
study also found, in most states, major gaps in workers' technical
knowledge of such topics as reproductive physiology. The study
points to the supervisory system as an important contributing factor
to these gaps in service quality, with only a minority of workers in
all four states indicating that their supervisors provided assistance in
improving their performance or addressing clients' needs.
Although they employ different research methodologies, the
qualitative study by Jagdish C. Bhatia in Karnataka (Chapter 10) and
the analysis of worker survey data by Aditi Iyer and Amar Jesani in
Maharashtra (Chapter 11) together provide insight into the barriers
that service providers face in providing reasonable standards of care
to clients. In two states characterized by considerable success in fam
ily planning performance, the studies nonetheless describe a range
of factors that constrain effective and high-quality service delivery.
These include nonresidence of providers due to inadequate housing
or schools, inadequate infrastructure, chronic shortages of key medi
cines and supplies, limited outreach efforts by female workers due in
part to frequent sexual harassment and fears for personal security,
and institutionalized corruption. The study by Iyer and Jesani paints
a particularly compelling picture of the vulnerability of frontline fe
male workers in rural India in attempting to provide outreach serv
ices, and the almost complete absence of institutional support for their
work. Both studies highlight the central role that numerical con
traceptive targets play in shaping program priorities, the pressure
placed upon workers to achieve these targets, and how this empha
sis often compromises attention to servirp nnalitv TntprPdHnalv Hip
J:
9
study also reports that despite widespread dislike among workers of
method targets, a significant percentage believe that their removal
would have a negative impact upon program performance, a finding
that highlights the complexity of the current shift away from the tar
get system.
In Chapter 12, M. E. Khan, Bella C. Patel, and R. B. Gupta present
findings from a qualitative study of quality of care within the Uttar
Pradesh family planning program, as seen from the perspective of
service providers. The study describes a setting characterized by wide
spread organizational malaise and an overall absence of readiness to
provide high-quality services, and identifies a number of specific con
tributing factors. One important consideration relates to the personal
security of female service providers—a serious concern in much of
North India—which contributes both to high rates of nonresidence
among female paramedical workers in the communities in which they
are assigned to work and to a general reluctance to visit remote com
munities. Inadequate service infrastructure, systemic shortages of
equipment and medical and contraceptive supplies, and poor pro
gram management that limits outreach efforts are also identified as
constraints. The system of contraceptive method targets once again
emerges as a major deterrent to better standards of care, with evi
dence presented on how pressure to achieve method quotas leads to
the provision of clinical contraception despite serious contrain
dications and how access to abortion is linked with sterilization ac
ceptance. In addition, there is competition between health and
nonhealth personnel in recruiting family planning cases and wide
spread overreporting of numbers of temporary contraceptive method
acceptors. The finding that outreach workers in Uttar Pradesh are gen
erally required to fulfill only a fraction of their assigned quota of new
sterilization cases also raises important questions about the overall
demographic efficacy of this approach.
Part III presents evidence on the quality of care provided in ster
ilization camps, where significant numbers of operative procedures
are performed en masse. Sterilization camps remain a primary source
of clinical contraceptive services throughout much of rural India to
day. Chapter 13 by Lakshmi Ramachandar and Sandhya Barge on
Madhya Pradesh, Chapter 14 by Dileep Mavalankar and Bharti
Sharma on Gujarat, and Chapter 15 by John W. Townsend, M. E. Khan,
and R. B. Gupta on Uttar Pradesh provide a broad and rpmarkAhlv
I
■
10
Introduction
consistent picture of the quality of care concerns that characterize this
service delivery approach. The capacity of such camps to offer high
standards of care appears to vary by location, with the quality of care
most problematic in outreach settings. Although surgeons appear to
be well-trained, the support systems for providing high standards of
technical care are generally inadequate. All three studies note rou
tine shortcuts in the sterilization of surgical equipment and instru
ments and in overall infection control measures, thus raising serious
concerns about potential infection transmission. All observe major
shortcomings in the extent of client-centered facilities. Running wa
ter and toilet facilities are often unavailable, and services are charac
terized by extended preoperative waiting times, little preoperative
instruction or patient counseling, insufficient concern for patient pri
vacy, and inadequate postoperative recovery facilities and recupera
tion time. While noting the continued importance of this service ap
proach given the absence of infrastructure in much of rural India, the
studies identify a number of aspects through which the quality of care
in sterilization camps could be significantly improved.
Part IV presents programmatic evidence and policy issues asso
ciated with improving quality of care. Of central policy and program
matic importance is the question of how improvements in quality of
care affect contraceptive use and demographic behavior. Yet, despite
a decade of intensive interest in quality of care within the family plan
ning field, evidence on the impact of quality of care upon contracep
tive and fertility behavior remains limited, both in India and in the
developing world more generally.4 The study by Daxa Patel, Anil
Patel, and Ambrish Mehta in Chapter 16 presents some of the first
empirical evidence from an intervention project demonstrating how
improvements in quality of care may contribute to improved patterns
of contraceptive use. Analyzing the experience of Action Research in
Community Health (ARCH), a volunteer organization in rural Gujarat,
the authors document how small improvements in service approach
and quality such as educating clients on reproductive anatomy,
demonstrating how IUDs work, addressing women's fears and con
cerns through counseling, and providing information on method com
plications—resulted in significant reductions in IUD dropout rates.
In the final chapter. Jay Satia and Sangeeta Subramanian Sokhi
(Chapter 17) examine the policy and management options associated
with the Indian government's stated policy shift away from contra-
Michael A. Koenig
11
ceptive method targets. The experience gained from six case studies
in India, where experiments with alternatives to method-specific con
traceptive targets are underway, is initially reviewed. The authors em
phasize the critical importance of substituting method-specific tar
gets with other alternative strategic "drivers"—indicators that provide
the driving force for the overall program. Potential alternative pro
gram drivers include increased client service access and availability,
better performance and coverage, and higher quality of care and/or
impact indicators. The authors raise a number of unresolved ques
tions relevant to India's ongoing efforts to shift away from method
specific targets: Should different indicators be employed in different
geographical areas depending upon their level of development?
Should there be a gradual and phased development of alternative in
dicators? What requisite changes in supervisory and management in
formation systems must accompany this programmatic shift?
Program Implications
The studies included in this volume collectively provide the most com
prehensive and up-to-date picture of the Indian family planning pro
gram in terms of actual implementation at the field level. In a study <»l
this nature, some degree of repetition and duplication in findings is per
haps inevitable. It is precisely this overlap and congruency in findings,
however, that lends credence to the conclusion that many of the quality
of care concerns described in this volume are systemic in nature and
characteristic of the Indian Family Welfare Programme as a whole.
While many of the findings reported are by no means novel, col
lectively they provide a compelling and disquieting picture of the re
alities of family planning service delivery within India's public sec
tor. The general view that emerges is of a program that has, over time,
seriously strayed from its initial mandate to improve the health and
wellbeing of Indian women and their families. India's Family Wel
fare Programme remains characterized by an overriding concern for
numbers—as measured by the recruitment of sterilization acceptors—
frequently at the expense of higher-quality, client-centered service.
While such gaps are perhaps most acute in the large, populous North
Indian states, many of the same quality of care concerns are also evi
dent within the Central and South Indian states, the latter now widely
recognized as emerging demographic success stories.
i
5
i
12
Introduction
The studies in this volume also provide insight into the numer
ous and frequently reinforcing factors that constrain quality of care
within the Indian program, and the links between many of these fac
tors and India's low level of socioeconomic development. Despite gov
ernment commitment to family planning, resource limitations remain
a serious impediment to higher quality services at all levels of the
delivery system. Basic buildings and infrastructure are underfunded,
especially at the peripheral level. Suitable transportation is lacking,
and there are chronic shortages of most basic medicines and supplies.
A second set of constraints relates to gaps in program management,
as reflected in such areas as inadequate staff training, weak supervi
sory support, the frequent failure to adhere to acceptable clinical stan
dards, limited accountability among program personnel, and wide
spread corruption. It is also clear from many studies in this volume
that basic program philosophy and orientation—as reflected in the
prevailing system of worker targets and program performance indi
cators and the corresponding low priority attached to the needs of
individual clients has played a central role in shaping current stan
dards of care provided within the Indian program.
Despite what might be widely regarded as substandard levels
of care, the studies in this volume also highlight the complexity of
this issue and the importance of placing findings on quality of care
in appropriate perspective. The problems described are clearly not
unique to India, but broadly characteristic of health and family plan
ning services in many, if not most, developing-country settings. In
many ways, quality of care represents a set of standards and ideals
that few programs—including those in more developed. Western set
tings—have yet to satisfactorily attain.
Moreover, family planning programs function not in isolation
but within the broader context of social relations in a particular set
ting. Within India, these relations are determined largely on the ba
sis of caste, social class, and gender. Within such systems, the poor,
especially poor women, have traditionally been accorded few rights-^
including the right to receive sympathetic and respectful treatment.
Many of the constraints and organizational impediments to better
quality of care outlined in this volume are thus systemic in nature,
and may characterize public sector bureaucracies in India and South
Asia as a whole. There is little evidence to suggest that the efficiency
or standards of care are significantly poorer within the family plan-
Michael A. Koenig
13
rung program than in other social development programs in South
Asia; considerable room for improvement is evident in most sectors.5
The results from this volume also highlight the complex and sub
jective nature of quality of care, and the extent to which this dimension
is tied to individual expectations. Despite what could frequently be
regarded as substandard levels of care by Western standards, it is
striking that significant numbers of clients express satisfaction with
existing family planning services, and appear to welcome more, rather
than less, contact with program staff. Moreover, the fact that a major
ity of women in Central and South India have adopted contraception
(overwhelmingly female sterilization) may indicate that, under con
ditions of strong motivation for small families and autonomy among
women to make fertility choices, small families may be achieved
despite the barriers to fertility regulation presented by poor quality
of care.
The findings nevertheless leave the reader with the unequivocal
impression that an absence of attention and priority to client needs
and poor overall quality of care have played important roles in the
disappointing performance of the Indian Family Welfare Programme
to date. The potential costs of poor-quality services can also be readily
discerned from many of the studies considered—as reflected in lower
levels of client satisfaction, a poor image and general distrust of the
public sector system, and weak commitment and low esprit de corps
among family planning staff. Although, as suggested by Chapter 16,
empirical evidence remains extremely limited, poor quality of care
may also contribute to high levels of delayed, forgone, or discontin
ued use of contraception and resulting unwanted pregnancy. Clearly
much more attention to this issue is warranted.
The government of India has recently taken the first tentative
steps toward addressing many of problems described within this vol
ume, through the reorientation of the current Family Welfare
Programme toward greater concern for service quality and clients'
broader reproductive health needs. In early 1996, the government
abolished the nationwide system of contraceptive method targets,
which has dominated the family planning program for much of its
existence. In late 1997, the government launched the new Reproduc
tive and Child Health Programme to replace the much narrower pro
grams on MCH and family planning, with the objective of more ef
fectively addressing the broader reproductive health needs of the
14
Introduction
family. Given the fact these policy changes were made only recently,
their implementation remains uneven and incomplete, and it is too
early to assess their impact at the field level.6
Nevertheless, the policy shift toward more client-centered ser
vices represents a highly significant and positive step, and, if accom
plished, is likely to yield substantial dividends —not only in terms of
meeting clients' reproductive needs but in terms of India's broader
demographic goals. Yet the evidence from this volume attests to the
enormity of the task at hand and the uncertainty of success. Progress is
likely to be measured more in decades than in years. A clear under
standing and recognition of the nature of the problems confronting the
Indian Family Welfare Programme represent important first steps to
ward effectively addressing them. It is hoped that the present volume,
by providing a detailed and candid picture of the realities of service
delivery at the field level, will make a contribution toward this end.
Notes
1
2
3
4
5
6
For an analysis of the demographic situation in the northern states, see Satia
and Jejeebhoy 1991.
For a review of existing research on quality of care within the Indian pro
gram, see Koenig, Foo, and Joshi 1999.
For a summary of research findings from the workshop, see Foo 1996.
See, for example, Pariani, Heer, and Van Arsdol 1991; Mensch, ArendsKuenning, and Jain 1996; Mensch et al. 1997; and Koenig, Hossain, and
Whittaker 1997.
See, for example, Dutta 1996 on local governance, Rahman 1999 on
women's savings and credit programs, Saxena 1997 on forest management,
and Weiner 1991 on education.
For an early attempt at assessment, see Visaria and Visaria 1998.
References
Basu, A.M. 1985. "Family planning and the Emergency: An unanticipated con
sequence," Economic and Political Weekly 20(10): 422-425.
Berman, P. and M.E. Khan (eds.). 1993. Paying for India's Health Care. New Delhi:
Sage Publications.
Bruce, Judith. 1990. "Fundamental elements of the quality of care: A simple
framework," Studies in Family Planning 21(2): 61-91.
Cassen, R.H. 1978. India: Population, Economy, Society. New York: Holmes and
Meier Publishers.
Conly, S.R. and S.L. Camp. 1992. India s Family Planning Challenge: From Rhetoric
to Action. Country Study Series No. 2. Washington, D.C.: Population Crisis
Committee.
Michael A. Koenig
15
Donabedian, A. 1988. "The quality of care: How can it be assessed?" Journal of
the American Medical Association 260(12): 1743-1748.
Dutta, B. (ed.). 1996. And Who Will Make the Chappatis? A Study of All-women
Panchayati in Maharashtra 1962-1995. Pune: Aalochana Centre for Documen
tation and Research on Women.
Foo, G.H.C. 1996. A Synthesis of Research Findings on Quality of Care Within the
Indian Family Welfare Progamme. New Delhi: Population Council.
Gwatkin, D.R. 1979. "Political will and family planning: The implications of India's
Emergency experience," Population and Development Review 5(1): 29-59.
Indian Council of Medical Research (1CMR). 1991. Evaluation of Quality of Family
Welfare Services at Primary Health Centre Level: An ICMR Task Force Study.
New Delhi: ICMR.
International Institute for Population Sciences (UPS). 1995. National Family Health
Survey (MCH and Family Planning): India, 1992-93. Bombay (Mumbai): UPS.
Kocher, J.E. 1980. "Population policy in India: Recent developments and cur
rent prospects," Population and Development Review 6(2): 299-310.
Koenig, M.A., G.H.C. Foo, and K. Joshi. 1999. "Quality of care within the Indian
Family Welfare Program: A review of recent evidence," Johns Hopkins
Population Center Working Paper, WP No. 99-01.
Koenig, M.A., M.B. Hossain, and M. Whittaker. 1997. "The influence of quality
of care upon contraceptive use in rural Bangladesh," Studies in Family Plan
ning 28(4): 278-289.
Measham, A.R. and R.A. Heaver. 1996. India's Family Welfare Programme: Moving to
a Reproductive and Child Health Approach. Washington, D.C.: The World Bank.
Mensch, B., M. Arends-Kuenning, and A. Jain. 1996. "The impact of the quality
of family planning services on contraceptive use in Peru," Studies in Family
Planning 27(2): 59-75.
Mensch, B., M. Arends-Kuenning, A. Jain, and M.R. Garate. 1997. "Avoiding
unintended pregnancy in Peru: Does the quality of family planning serv
ices matter?" International Family Planning Perspectives 23(1): 21-27.
Misra, B.D., G.B. Simmons, A. Ashraf, and R. Simmons. 1982. Organization for
Change: A Systems Analysis of Family Planning in Rural India. Ann Arbor:
University of Michigan Center for South and Southeast Asian Studies.
Narayana, G. and J.F. Kantner. 1992. Doing the Needful: The Dilemma of India's
Population Policy. Boulder, Colo.: Westview Press.
Pai Panandiker, V.A. and P.K. Umashankar. 1994. "Fertility control and politics
in India," in The New Politics of Population: Conflict and Consensus in Family
Planning, eds. J.L. Finkle and C.A. McIntosh. Population and Development
Review, supplement to Vol. 20, pp. 89-104.
Pariani,S, D.M. Heer, and M.D. Van Arsdol, Jr. 1991. "Does choice make a dif
ference to contraceptive use? Evidence from East Java," Studies in Family
Planning 22(6): 384-390.
Rahman, A. 1999. "Micro-credit initiatives for equitable and sustainable devel
opment: Who pays?" World Development 27(1): 67-82.
Satia, J.K. and G. Giridhar. 1991. "Supply aspects of meeting demand for family
planning," in The Demographic Challenge: A Study of Four Large Indian States,
eds. J.K. Satia and Shireen J. Jejeebhoy. Bombay: Oxford University Press,
pp. 178-213.
Satia, J.K. and SJ. Jejeebhoy (eds.). 1991. The Demographic Challenge: A Study of
Four Large Indian States. Bombay: Oxford University Press.
16
Introduction
Saxena, N.C. 1997. The Saga of Participatory Forest Management in India. Jakarta:
Centre for International Forestry Research.
Simmons, R.S. and A. Ashraf. 1978. "Implementing family planning in a minis
try of health: Organizational barriers at the state and district levels," Stud
ies in Family Planning 9(2/3): 21-34.
Soni, V. 1983. "Thirty years of the Indian family planning program: Past perfor
mance, future prospects," International Family Planning Perspectives 9(2): 3544.
Visaria, L., S. Jejeebhoy, and T. Merrick. 1997. "From family planning to reproduc
tive health," paper presented at the XXIII General Assembly of the Interna
tional Union for the Scientific Study of Population, Beijing, 11-17 October.
Visaria, L. and P. Visaria. 1998. Reproductive Health in Policy and Practice: India.
Washington, D.C.: Population Reference Bureau.
Visaria, P. and V. Chari. 1998. "India's population policy and family planning pro
gram," in Do Population Policies Matter? Fertility and Politics in Egypt, India, Kenya,
and Mexico, ed. Anrudh Jain. New York: Population Council, pp. 53-112
Weiner, M. 1991. The Child and the State in India. Delhi: Oxford University Press.
World Bank. 1995. India: Policy and Finance Strategies for Strengthening Primary
Health Care Services. Population and Human Resources Division, Report
No. 13042-IN. Washington, D.C.: World Bank.
Part I.
Client Perspectives
on the Quality of Care
2
Women's Perceptions of the
Quality of Family Welfare
Services in Four Indian States
T. K. ROY & RAVI K. VERMA
One of the important contributions of the quality-of-care framework
as suggested by Bruce (1990) is that it has brought the client's per
spective into focus. Bruce and others (e.g., Satia and Giridhar 1991)
have argued that assessments of the quality of reproductive health
services should be based on the recipients' perceptions of services
received, rather than on the providers' perceptions of services ren
dered. Since it is women who constitute the great majority of the cli
entele of family planning programs, Bruce (1981) has argued that it
is important to understand women's experiences of family planning
and reproductive health care services before designing client-oriented
family welfare programs.
Although detailed, comprehensive information is not available
on the quality of the Indian Family Welfare Programme's services, <i
number of studies have shown that women's reasons for not accept
ing family planning methods include the fear of side effects, the lim
ited variety of methods available, and lack of knowledge about con
traceptives (UPS 1995; Khan 1988; Misra et al. 1982; Roy et al. 1991).
In a recent study based on 20 small focus-group discussions with cur
rently married men and women in Uttar Pradesh, individuals said
that they had not adopted family planning because they did not know
enough about the methods (Levine et al. 1992). Some respondents also
reported that although they were aware of the methods, they had not
had this knowledge during the initial years of their married life. The
study results indicate that government health personnel often do not
20
T. K. Roy • Ravi K. Verma
Women's Perceptions in Four Indian States
actively involve clients in choosing a particular method. Doctors and
others tend to decide on the suitability of a particular method for the
client, and in most cases the client is not told of the potential side
effects of the method before adopting it. Both men and women in the
focus-group discussion felt that this information on side effects had
been deliberately withheld from them because program staff feared
that the information might act as a deterrent to acceptance.
The quality of family planning care is important at three stages—
preacceptance counseling and clinical checkup, acceptance, and
postacceptance follow-up. Satia and Giridhar (1991) have pointed out
that although postacceptance follow-up has received much attention
in the literature, little is documented about the preacceptance phase.
It is against this backdrop of limited knowledge of clients' percep
tion and experience that we have undertaken the present study.
The primary objective of this chapter is to describe the experi
ences and perceptions of eligible women in the rural areas of four
Indian states regarding the standards of care offered by the Indian
Family Welfare Programme. Our analysis addresses the following di
mensions of quality of care: (1) contact with the government program,
(2) availability of method choice, (3) types and range of information
given to clients, (4) quality of interpersonal relations between pro
viders and clients, and (5) appropriateness of services provided. The
study focuses primarily on women's experiences with and perceptions
of the program. No attempt is made to demonstrate the effects of those
perceptions and experiences on their actual family planning behavior.
Data
Our data come from studies conducted in 1994 at the International
Institute for Population Sciences (UPS) in Mumbai (Verma and Roy
1994; Verma, Roy, and Saxena 1994). Studies on quality of care and
services were undertaken in each of four states: Tamil Nadu and
Karnataka in the south, and West Bengal and Bihar in the north. The
states were chosen on the basis of their family planning performance
as measured by the fulfillment of contraceptive targets. According to
the National Family Health Survey (NFHS), which canvassed a na
tionally representative sample of nearly 90,000 ever-married women,
tlie proportion of currently married women aged 13-49 using any con
I
,I
f
i
a
21
traceptive method in 1992-93 was only 22 percent in Bihar, 37 per
cent in West Bengal, 45 percent in Tamil Nadu, and 47 percent in
Karnataka (UPS 1995). In each state, three districts were also chosen
on the basis of their performance in the Family Welfare Programme,
as reflected in rates of contraceptive use. Our objective was to cap
ture the range of variation in the quality of services within each state.
With this end in view, we selected one district each in the high, me
dium, and low categories of performance. We then selected six catch
ment areas from primary health centers (PHCs) in each district. The
criterion for PHC selection was similar to that for the selection of dis
tricts: two PHCs each were selected from the categories of high, me
dium, and low performance, for a total of 18 PHCs in each state.
From each selected PHC, we collected data on the perceptions
and experiences of three subsets of women. The first subset was se
lected from the village or community on the basis of a sample sur
vey. Fifty eligible women—that is, currently married women in the
reproductive age group of 15^49 years—were selected from villages
served by each PHC as follows: The villages were subdivided into
three groups according to their distance from the service center. One
village from each distance group was chosen. The samples of 50
women were selected systematically from lists of households avail
able from each village panchayat (council) and distributed equally
among the three villages. The total number of eligible women inter
viewed in the four states was 3,585. Of these, 894 were interviewed
in Bihar, 894 in West Bengal, 899 in Tamil Nadu, and 898 in Karnataka.
We refer to these women as "eligible women interviewed in the vil
lage or community."
It should be noted that these 50 women may or may not have
been recent users of family planning services from the neighboring
PHC. Their perceptions of the various dimensions of the quality of
care available from the PHC therefore may not have been based on
direct personal experience. For that reason we decided also to include
in the study some women who had actually used the family plan
ning services of the PHC or subcenter. As it was not always possible
to find women who had approached the PHC exclusively for family
planning services, we decided to interview 30 eligible women who
had used any of the PHC's health services and also those who had
come to seek family planning services, immediately after they had
<
■
I
1
22
Women's Perceptions in Four Indian States
received the services. This group of women forms our second source
of data. The total number of such eligible women who were inter
viewed on the PHC premises ("eligible women interviewed at the
clinic") immediately after using these services was 1,855: 302 in Bihar,
523 in West Bengal, 529 in Tamil Nadu, and 501 in Karnataka.
Of these 1,855 women, only 355 had come to the PHC specifi
cally seeking family planning services: 26 in Bihar, 197 in West Ben
gal, 95 in Tamil Nadu, and 37 in Karnataka. This subgroup of women
is referred to as "family planning acceptors." Details of the back
ground characteristics of all three subsets of women are described
elsewhere (Verma and Roy 1994; Verma, Roy, and Saxena 1994).
Findings
Respondents were asked a number of questions on their perceptions
of the quality of care provided by government PHCs and subcenters
in their respective districts. In presenting our findings, we consider
the extent of respondents' contact with the government program, the
choice of methods, information given to the clients, clients' interper
sonal relations with program personnel, and the appropriateness of
the constellation of services.
Contact with the Government Program
We assessed the contact with the government program from the re
sponses of the eligible women who were interviewed in their com
munity. Seven of 10 respondents in Tamil Nadu, Karnataka, and Bihar
and nearly 6 of 10 respondents in West Bengal had visited a govern
ment clinic during the preceding six months (Table 2.1). A majority
of women in all four states also reported that they had received a
visit from an auxiliary nurse-midwife (ANM) during the preceding
three months. The proportions of respondents mentioning a home
visit ranged from 93 percent in Karnataka and 89 percent in Tamil
Nadu, to 61 percent in West Bengal and 53 percent in Bihar. The find
ings indicate a clear demarcation between the northern and southern
states in the level of contact with the public-sector program. Never
theless, significant levels of interaction with the government program
were evident in all four of the states studied.
T. K. Roy • Ravi K. Verma
TABLE 2.1
Contact between clients and government service providers:
Four Indian states, 1994
Percentage of respondents
Type of contact
Bihar
Visited government clinic
in the last six months
70
Visited by ANM in the last three months
53
(No. of respondents)
(894)
West Bengal Tamil Nadu
58
61
(894)
73
89
(899)
Karnataka
74
93
(898)
ANM=auxiliary nurse-midwife.
Method Choice
A program that seeks to cater to clients' contraceptive needs is ex
pected to offer a range of methods on a reliable basis. Women who
wish to space their births obviously need different methods from those
who wish to stop bearing children altogether. Younger women and
those who desire to have children in the future would be clearly at
tracted to spacing rather than terminal methods such as female ster
ilization. Similarly, it is important to identify those women who can
not tolerate specific methods, such as hormonal contraceptives.
Women's perceptions of the emphasis placed by service provid
ers on sterilization versus spacing methods reflect the range of method
choices available to them. According to substantial majorities of re
spondents interviewed in the villages, providers at government clin
ics in all four states sometimes or always advocated sterilization (Table
2.2). Emphasis on sterilization appears to have been especially pro
nounced in Tamil Nadu and Karnataka, where more than half of the
women gave this response. In Bihar and West Bengal about a third of
the women said that clinic staff always emphasized sterilization. How
ever, in all four states, a majority of respondents also reported that
clinic staff always or sometimes suggested spacing methods (rang
ing from 63 percent in Bihar to 81 percent in Karnataka).
Respondents were also asked what kind of information the ANM
gave them during home visits. With the exception of Bihar (42 per
cent), more than one-half of the respondents reported that the ANM
mentioned at least one method (either sterilization only or both ster
ilization and spacing methods). These results also indicate a strong
emphasis on sterilization by ANMs during outreach visits.
24
Women's Perceptions in Four Indian States
TABLE 2.2
Choice of contraceptive methods: Four Indian states, 1994
T. K. Roy • Ravi K. Verma
TABLE 2.3
Information given to clients: Four Indian states, 1994
Percentage of respondents
Measure
Women interviewed in the villages
Clinic staff emphasize sterilization
Always
Sometimes
Rarely
Clinic staff also suggest
spacing methods
Always
Sometimes
Rarely
Bihar
West Bengal Tamil Nadu
Percentage of respondents
Karnataka
27
39
34
36
34
30
21
42
38
39
31
2n
50
23
27
49
32
19
24
39
28
21
(No. of respondents)
18
(894)
26
(894)
26
(899)
43
(898)
Family planning acceptors
(exit interviews)
Received desired method
(No. of respondents)
96
(26)
96
(197)
96
(95)
70
(37)
ANM discusses
Sterilization only
Both sterilization and
spacing methods
58
23
19
56
33
11
Indicator
Women interviewed in the villages
ANM discusses side effects
Always
Sometimes
Rarely
(No. of respondents)
Note: Percentages may not add to 100 because of rounding.
ANM=auxiliary nurse-midwife.
We further examined the extent of method choice by interview
ing family planning acceptors soon after they had sought the family
planning services at their clinic. Nearly all acceptors in Bihar, West
Bengal, and Tamil Nadu (96 percent), but only 70 percent of accep
tors in Karnataka, said that they had received the method of their
choice. The validity of these results may be open to question, how
ever, since in a situation of limited method choice, program person
nel may be able to persuade most women to accept a method empha
sized by the program, and acceptors tend to believe that they have
made a free choice. The pattern of contraceptive use in India as a
whole suggests limited contraceptive choice. Although many women
might be better served by spacing methods, the NFHS found female ster
ilization to be the most widely used contraceptive method in India, ac
counting for 67 percent of current contraceptive prevalence (BPS 1995).
Information Given to Clients
Another indicator of quality of care is whether sufficient and accu
rate information is imparted during service contacts to enable clients
Bihar
18
35
47
(894)
Family planning acceptors (exit interviews)
How method works
85
How to use method
65
Possible side effects
58
How to deal with side effects
58
(No. of respondents)
(26)
West Bengal Tamil Nadu
Karnataka
23
30
45
(894)
52
19
29
(899)
56
28
16
(898)
59
57
40
37
(197)
59
59
47
40
(95)
97
81
89
78
(37)
-
Note: Percentages may not add to 100 because of rounding.
ANM=auxiliary nurse-midwife.
to make informed choices. Most important is whether clients receive
information about contraindications and possible side effects of avail
able contraceptive methods. Ideally, clients should be informed on
how each method works, how to use the method, possible side ef
fects, and what to do if side effects occur.
Table 2.3 reveals that slightly more than one-half of the women
interviewed in Tamil Nadu (52 percent) and Karnataka (56 percent),
but fewer than one-fourth of those in Bihar (18 percent) and West
Bengal (23 percent), always received information on contraceptive side
effects or contraindications when they were visited by ANMs. Fur
ther substantiating the limited information given to clients are the
responses from the acceptors of family planning methods during exit
interviews at the clinics. Clients were asked about the information
that clinic staff had given them concerning the method they were us
ing. More than one-half of all acceptors in West Bengal and Tamil
Nadu (57-59 percent) reported that they had been given a descrip
tion of how the method worked and how to use the method. Less
than one-half of the women in those states were told about side ef
fects, and only 37 percent in West Bengal and 40 percent in Tamil Nadu
were told what to do in case of side effects. Although small numbers
of acceptors were interviewed in Bihar and Karnataka, their responses
indicate that a majority were given information about their method,
its possible side effects, and what to do in the event of side effects
h
26
Women's Perceptions in Four Indian States
Interpersonal Relations
Clients' satisfaction with a government clinic's services and their con
tinued use of those services are likely to depend significantly upon
the perceived behavior of clinic doctors and staff. We assessed the
quality of interpersonal relations established at the clinics from the
viewpoint of both women in the community and those we interviewed
at the clinics. We also assessed the quality of interpersonal relations
between village women and the ANMs during home visits. Respon
dents were asked how they had been treated by clinic staff: whether
the doctor was cordial, whether he or she paid adequate attention to
their family planning and health needs, and whether clinic staff had
provided them with privacy.
The distribution of responses, presented in Table 2.4, indicates a
marked contrast between the southern and northern Indian states,
with Tamil Nadu and Karnataka consistently performing higher. Al
most four-fifths of the women in Tamil Nadu and Karnataka reported
that the clinic staff were always cordial. High percentages of women
also said that they were always paid proper attention, and that the
clinic always provided adequate privacy. Fewer than 1 in 10 respon
dents expressed dissatisfaction with the quality of interpersonal
relations.
In Bihar and West Bengal, however, approval ratings were lower
and dissatisfaction greater. Only about one-half of women in Bihar
and 59 percent in West Bengal stated that the doctor or staff was al
ways cordial; and between 12 and 19 percent of the women believed
the staff was rarely cordial, rarely attentive, or the clinic rarely pro
vided adequate privacy. Bihar scored especially low on staff atten
tion, with only a third of women reporting that they always received
proper attention. Similarly, Bihar and West Bengal scored particu
larly low on privacy; only about 4 of 10 women reported that their
clinic always provided adequate privacy. It should be noted that clin
ics in Bihar and West Bengal cater to unusually large populations
(about 100,000 each), with consequent crowding, making it more diffi
cult for clinic staff to ensure a high quality of client-provider relations.
We also assessed the quality of village women's interpersonal
relations with health workers during home visits. Large majorities of
women in Tamil Nadu (82 percent) and Karnataka (76 percent) re
ported that the ANM always discharged her duties sincerely. Sub-
27
T. K. Roy • Ravi K. Verma
TABLE 2.4
Interpersonal relations with service providers as perceived
by women in the villages: Four Indian states, 1994
Percentage of respondents
Indicator
Care provided at the clinic
Clinic staff/doctor cordial
Always
Rarely
Staff/doctor gives proper attention
Always
Rarely
Clinic provides adequate privacy
Always
Rarely
Care provided during outreach visits
ANM discharges duties sincerely
Always
Rarely
ANM pays attention to
family planning needs
Always
Rarely
ANM generates confidence to accept/
continue contraceptive use
Always
Rarely
(No. of respondents)
Bihar
West Bengal Tamil Nadu
Karnataka
49
14
59
13
79
5
79
5
33
19
46
12
70
7
61
7
42
16
39
19
60
6
72
6
36
28
50
14
82
5
76
6
25
35
37
22
69
9
59
13
27
38
(894)
29
28
(894)
59
12
(899)
55
16
(898)
ANM = auxiliary nurse-midwife.
stantial majorities of respondents in both states (69 percent and 59
percent, respectively) said that the ANM always paid attention to their
family planning needs. Among women in Bihar and West Bengal,
however, impressions of health workers were much less positive. The
proportions giving the ANMs high marks ranged from 50 percent in
West Bengal (those who felt that the ANM was sincere) to only 25
percent in Bihar (those who thought that the ANM paid adequate
attention to their family planning needs). Substantial proportions of
women in Bihar thought that the ANM rarely discharged her duties
sincerely (28 percent), rarely paid attention to their family planning
needs (35 percent), and rarely generated confidence to accept or con
tinue contraceptive use (38 percent).
Exit interviews of women interviewed at the clinics revealed a
similar pattern (Table 2.5). Karnataka had the best record and Bihar
the worst with respect to quality of care. Privacy was considered to
be exceptionally low in West Bengal, where only about one-fourth of
28
T. K. Roy • Ravi K. Verma
Women's Perceptions in Four Indian States
TABLE 2.6
Appropriate constellation of services: Four Indian states, 1994
TABLE 2.5
Interpersonal relations with service providers as perceived
by women during exit interviews: Four Indian states, 1994
Percentage of respondents
Percentage of respondents
Perceived quality
Bihar
Doctor was cordial
43
40
45
52
(302)
Doctor gave adequate attention
Clinic privacy was adequate
Language was easy to understand
(No. of respondents)
West Bengal Tamil Nadu
53
45
27
72
(523)
66
62
63
71
(529)
29
Karnataka
79
69
74
79
(501)
1i
Indicator
Bihar
Average travel time to clinic
< 30 minutes
85
90
88
71
82
14
4
93
30
23
(302)
37
42
21
88
41
14
(523)
91
3
6
88
66
72
(529)
83
13
4
95
65
50
(501)
Average time taken to see doctor
< 30 minutes
30 minutes -1 hour
> 1 hour
Clinic office hours convenient
Doctor always available
the women felt that clinic privacy was adequate. This finding is sub
stantiated by the data from interviews in the villages of West Bengal,
where only 39 percent of women believed that the clinics had pro
vided adequate privacy. Approximately three-fourths of the respon
dents in West Bengal, Tamil Nadu, and Karnataka, but only about
one-half of those in Bihar, believed that the language used by the doc
tors was easy to understand.
Appropriate Constellation of Services
Another aspect of the quality of family planning and family health
services is the appropriateness of their configuration. An appropri
ate constellation of services is one that is convenient and acceptable
to clients, responds to their health concerns, and meets their health
needs. Long travel time to the clinic and long waiting time at the clinic
can be major barriers to the continued use of government services.
The availability of doctors and medicines, when needed, is an impor
tant service-related issue that affects clients' perceptions of services.
Doctor availability is hindered, however, by the fact that many are
urban-educated and prefer not to practice in rural areas for a variety
of reasons, including the lack of modern amenities and educational
facilities for their children. If a doctor is perceived to attend a gov
ernment clinic regularly, use of that facility is likely to increase.
For a large majority of women in the four states, the government
clinic was less than half an hour away in travel time (Table 2.6). In all
states but West Bengal, waiting time to see the doctor was less than
30 minutes for a high proportion of respondents. In West Bengal, 63
nprrpnt of resnondents rpnorted average waits of 30 miniifpq or morp
I
f. ■
Adequate medicines always available
(No. of respondents)
West Bengal Tamil Nadu
Karnataka
■
i
i
[
R
and 21 percent reported delays of more than one hour. Roughly 9
out of 10 women in all four states found the office hours of govern
ment clinics to be convenient. About two-thirds of women in
Karnataka and Tamil Nadu reported that a doctor was always avail
able in their government clinic. In Bihar and West Bengal, the pro
portions reporting that the doctor was always available were consid
erably lower—30 percent and 41 percent, respectively. Similarly, when
asked about the availability of medicines, respondents in Bihar and
West Bengal provided a much less positive picture than those in Tamil
Nadu and Karnataka. While 72 percent of women in Tamil Nadu and
50 percent of women in Karnataka reported that medicines were al
ways available, the percentages in Bihar and West Bengal were only
23 percent and 14 percent, respectively.
I ■
Summary and Conclusion
The approach we have used in this chapter—evaluating the quality
of care provided by the Indian Family Welfare Programme entirely
from the viewpoint of rural women—is not the only way to assess
quality of care. There is no dearth of evaluative studies and literature
on family planning management in India, and many of those studies
have touched upon issues relating to quality, at least indirectly. How
ever, those studies have for the most part not had women clients them
selves as their primary focus. Rather, they have tended to concen
trate on the quality of program inputs or on outputs in terms of
contraceptive adnntinn It ran bp nranpd fbaf ummon'c roremrHwn"
30
Women's Perceptions in Four Indian States
may be greatly influenced by personal factors that have little bearing
on program implementation. We undertook the present analysis to
counter this argument and to provide empirical evidence in support
of the thesis that to be effective, family planning programs must ac
cord women's perspectives due consideration.
The analysis has revealed wide variations in women's experiences
with, and perceptions of, the services offered by government clinic staff
and field workers. At the state level, variations followed an expected
pattern. Whereas a majority of women in the two southern Indian states
perceived that they had received (and presumably had experienced)
a reasonably high quality of services, most women in West Bengal and
Bihar did not report such positive perceptions or experiences.
In Tamil Nadu, for example, a significant majority of women in
terviewed reported that a doctor was always available at the PHC, that
the doctor s behavior was always cordial, that adequate medicines were
always available, that clinic staff always paid attention to their health
and family planning needs, and that the clinic always provided pri
vacy to family planning clients. Regarding the performance of health
workers, 8 out of 10 women in Tamil Nadu perceived their ANM to be
sincere, and two-thirds believed that the ANM paid adequate atten
tion to their family planning and health needs. Slightly more than
one-half of the Tamil Nadu women reported that ANMs had dis
cussed the side effects of contraceptives and related issues with them.
In contrast, the quality of services offered in Bihar appears to be
the poorest among all the states we have considered. Only about onethird of the women reported that a doctor was always available in the
PHC and, if available, was always attentive. Only about one-quarter
reported that medicines were always available. Three-fifths found their
clinic to lack adequate privacy. Three-quarters felt that ANMs paid
inadequate attention to their family planning and family health needs.
In Tamil Nadu and Karnataka, the majority of women reported
that government clinics emphasized sterilization. In West Bengal and
Bihar, government clinics did not appear to place emphasis on any
particular contraceptive method. It could be that the providers, par
ticularly in Bihar, were reluctant to promote family planning, and there
fore the decision about whether to accept contraception—and what
method to accept—was left entirely to the individual woman. This
study is unable to assess the extent to which government health work-
T. K. Roy • Ravi K. Verma
31
ers allow clients to make informed choices, since it is difficult for many
respondents to distinguish between mere provision of information and
actual emphasis on a method. It could be argued that by not promot
ing a particular method that may be inappropriate for some women,
the programs in West Bengal and Bihar maintain a higher quality of
care than do those in Karnataka and Tamil Nadu. In our view, how
ever, not informing clients about available methods is equivalent to
not providing a choice. Our findings suggest that women in all four
states need more, not less, information about available methods.
The perception voiced by some respondents—that PHCs had in
adequate supplies of medicines and did not provide privacy—is a
matter of concern that has serious implications for women's repro
ductive health. A large number of women in Bihar and West Bengal
were particularly concerned about these issues and about the poor
quality of services offered by ANMs. A program that caters to the
needs of women must address these issues if it is to be highly effec
tive. Clinic personnel need to ensure adequate privacy, attentiveness
to patients' problems, and courteous behavior on the part of the doc
tors. In addition, the services must reach out to all women irrespec
tive of their educational status or caste affiliation.
Acknowledgments
•i
II
Some of the data presented in this chapter, particularly those related to Tamil
Nadu, Karnataka, and West Bengal, are from a larger study entitled Quality of
Family Welfare Services and Care in Selected Indian States, which UPS, Mumbai,
undertook in 1994 with financial assistance from the United States Agency for
International Development (USAID). The data for Bihar are from a study en
titled Quality of Family Welfare Services and Care in Bihar, for which UPS pro
vided financial support. We are grateful to Michael Koenig for very useful com
ments on an earlier draft of the chapter. We also thank Sujata Visaria for her
meticulous editing and useful insights into the chapter. The help we received
from Dr. S. K. Singh, Mr. Praveen, Mr. Mandar, and Mr. Somnath of UPS while
preparing the chapter is gratefully acknowledged.
References
Bruce, Judith. 1981. "Women-oriented health care: New Hampshire Feminist
Health Center," Studies in Family Planning 12(10): 353-363.
--------- . 1990. "Fundamental elements of the quality of care: A simple frame
work," Studies in Family Planning 21(2): 61-91.
It
32
Women's Perceptions in Four Indian States
International Institute for Population Sciences (UPS). 1995. National Family Health
Survey (MCHand Family Planning): India, 1992-93. Bombay (Mumbai): UPS.
Khan, M.E. 1988. Performance of Health and Family Welfare Programmes in India.
Bombay (Mumbai): Himalayan Publishing House.
Levine, Ruth E., H.E. Cross, S. Chhabra, and H. Viswanathan. 1992. "Quality of
health and family planning services in rural Uttar Pradesh: The clients'
view," Demography India 21(2): 247-266.
Misra, B.D., George B. Simmons, Ali Ashraf, and Ruth S. Simmons. 1982. Organ
ization for Change: A Systems Analysis of Family Planning in Rural India. New
Delhi: Radiant Publishers.
Roy, T.K., D. Radha Devi, Ravi K. Verma, Sulabha Parasuraman, and Balram
Paswan. 1991. Health Services and Family Planning in Rural Maharashtra: A
Report of Baseline Survey in Bhandara, Chandrapur, Dhule and Nagpur Districts.
Bombay (Mumbai): International Institute for Population Sciences.
Satia, J.K., and G. Giridhar. 1991. "Supply aspects of meeting demand for fam
ily planning," in The Demographic Challenge: A Study of Four Large Indian
States, eds. J.K. Satia and Shireen J. Jejeebhoy. Bombay: Oxford University
Press, pp. 178-213.
Verma, Ravi K. and T.K. Roy. 1994. Quality of Family Welfare Services and Care in
Bihar. Bombay (Mumbai): International Institute for Population Sciences.
Verma, Ravi K., T.K. Roy, and P.C. Saxena. 1994. Quality of Family Welfare Serv
ices and Care in Selected Indian States. Bombay (Mumbai): International In
stitute for Population Sciences.
3
The Quality of Family Welfare
Services in Rural Maharashtra:
Insights from a Client Survey
nirmala Murthy
I
I
For the last three decades, India's Family Welfare Programme has
pursued the goal of reducing fertility as rapidly as possible. Until re
cently the means used to achieve this goal were method-specific con
traceptive targets and cash incentives for acceptors. The Indian gov
ernment has recognized that this approach has failed to produce the
desired reduction in fertility because it has emphasized targets and
incentives to the detriment of quality. To remedy the situation, the
government has adopted a reproductive health approach for deliver
ing family welfare services and has taken the critical step of remov
ing method-specific contraceptive targets. In addition, the government
has decided that the Family Welfare Programme should focus on qual
ity of care, client satisfaction, and service coverage. This chapter pre
sents results from a survey designed to assess the quality of care of,
and client satisfaction with, the Family Welfare Programme in a dis
trict in rural Maharashtra. The study also identifies specific program
elements deemed to be detrimental and client characteristics that in
fluence program quality and client satisfaction.
Bruce (1990) identified six criteria for evaluating the quality of
family planning services: (1) method choice, (2) information given to
clients, (3) technical competence of the service provider, (4) interper
sonal relations between client and service provider, (5) mechanisms
to encourage continuity, (6) and appropriate constellation of services.
In Bruce's view, a program having these six elements can be assumed
to provide good service. Jain (1992) contends there is no firm evidence
"IT
34
Quality of Services in Rural Maharashtra
that all these elements represent a high quality of services for clients;
however, studies we reviewed in India and elsewhere have confirmed
that clients satisfaction is related to most of these elements and that
client satisfaction leads to the acceptance of services.
In a study in Santiago, Chile, for example, Vera (1993) found that
clients considered the most important elements of service quality to
be a clean and hygienic place; prompt service; treatment as an equal
by service providers; useful information and the opportunity to learn;
enough time to consult with the staff; cordial, likable, and friendly
staff; and access to prescribed medicines. In Vera's study, women fre
quently mentioned how much they appreciated being treated as respon
sible adults that is, not scolded or made to feel ignorant. This element
of interpersonal relations was more important in their assessment of qual
ity than the competence of staff or effectiveness of treatment.
Several Indian studies have reported that the rude behavior of
health staff has been a major reason why women have not liked or
used the government health services. A study in the state of Gujarat
found that 20 percent of clients were not satisfied with the govern
ment services because they had to wait too long for the services and
the staff did not treat them properly (Visaria and Visaria 1990). Nearly
60 percent of the respondents in the study reported going to private
doctors because those doctors provided better-quality services, even
though government hospitals had better diagnostic equipment and
better-trained doctors.
Government health functionaries usually blame the lack of equipment and supplies for the poor quality of their services. Ramasundaram (1994), however, has observed that even when equipment
and supplies were made available, clients of the government's Fam
ily Welfare Programme received poor quality of care. He attributed
this to the attitudes of health workers, who showed little respect for
clients, especially if they were poor, illiterate, or from lower social
strata. Some health workers even believed that because the govern
ment provided free services and also gave cash incentives for steriliza
tion operations, the clients had no right to demand good-quality services.
Other factors that can affect service quality include the lack of
critical services, such as emergency obstetric care and treatment for
reproductive tract infections and sexually transmitted diseases; the
lack at some subcenters (SCs) of such routine services as complete
Nirmala Murthy
I
•
■
antenatal care (ranging from the administration of tetanus toxoid [TI ]
to urine examinations); the failure to provide adequate information
to acceptors of family planning methods; the failure to check clients
for contraindications before inserting intrauterine devices (IUDs) or
prescribing oral contraceptives; and the failure to provide adequate
follow-up care or counseling (World Bank 1995).
In a study of nine districts in four Indian states, Verma, Roy, and
Saxena (1994) found that clients' perceptions of program quality had
a significant effect on their acceptance of family planning services.
The quality dimensions used in their study were: (1) the quality of
doctors (i.e., availability of doctors, attention paid by doctors to cli
ents' concerns, and whether doctors suggested spacing methods); (2)
the quality of facilities (i.e., availability of medicines, cleanliness of
facilities, and provision of privacy); (3) the quality of workers (their
perceived sincerity, attention to clients, and ability to generate confi
dence); and (4) the time involved in obtaining services (the amount
of time required to reach the clinic, waiting time, and time taken for
service). The study found a high correlation among the first three di
mensions of quality. Clients rated program quality as "very good"
when they found all three elements—doctors, facilities, and work
ers—to be of good quality. Further, the use of family planning meth
ods was significantly higher among those who considered program
quality to be very good than among those who did not.
These studies suggest that clients recognize program quality
when they encounter it, that higher program quality leads to greater
client satisfaction and thus to greater acceptance of services, and that
clients possibly assess service quality more on the basis of the quality
of the delivery process than upon its technical content. It is therefore
important to understand the delivery process and how it can be in
fluenced to improve service quality.
The quality of the service-delivery process is a product of many
interactions that take place between service providers and clients.
Those interactions are so numerous and occur at so many points—in
homes, clinics, and service camps—that program managers who are
responsible for program quality can neither standardize them nor di
rectly monitor them (Parasuraman, Zeithaml, and Barry 1988). Man
agers can try to influence them, however, if they know how clients
assess the quality of a delivery process, what factors influence qual-
u
36
Quality of Services in Rural Maharashtra
ity, and how to modify those factors. This chapter focuses on vari
ables that influence the quality of the delivery process.
Nirmala Murthy
37
TABLE 3.1
Coverage of family welfare services, by clients’ background
characteristics: Ahmednagar District, Maharashtra, 1994
Characteristic
(No.)
Antenatal care
registrations
(%)
Residence
PHC/SC villages
Other villages
(673)
(350)
Mother’s education
Illiterate
Literate
Economic status
Poor
Not poor
The Data
Data for this operations research project were collected from Earner
Block of Ahmednagar District in Maharashtra. Earner Block has a
population of about 200,000, spread over 131 villages. Among these
villages there are seven primary health centers (EHCs) and 31 SCs;
the remaining 93 villages have no government health facilities. The
project was conducted jointly by the Directorate of Health Services
of Maharashtra and the Foundation for Research in Health Systems,
a nongovernmental organization (NGO). The state government took
responsibility for implementing the project, while the NGO provided
research support and helped the government think through systemic
improvements. A state-level steering committee! was set up to guide
and monitor the progress.
A baseline survey was conducted in January 1994 to set quanti
tative benchmarks for project activities. The sample consisted of 1,023
married women of reproductive age (under age 45), chosen from 40
randomly selected villages in the block. Because the probability that
a village would be selected was proportional to its population, 7 EHC
villages, 17 SC villages, and 16 villages without health facilities ("other
villages ) were included in the sample. The survey gathered infor
mation about local maternal and child health care services from 624
mothers whose children were less than 5 years old and also informa
tion about family planning from all 1,023 women in the sample. In
formation gathered about the women's background characteristics
included their education, type of house, household possessions, caste,
and type of health services available in the village. Families who lived
in kuccha houses (houses with thatched roofs) and did not possess
such items as a radio, bicycle, or electricity were classified as poor.
Families belonging to lower social castes and tribes as defined by the
Indian government were classified as scheduled castes or tribes. Fi
nally, auxiliary nurse-midwives (ANMs) and doctors from the Fam
ily Welfare Erogramme were interviewed to obtain information on
the technical content of services and on service providers' perspec
tives on selected service-delivery processes.
Social status
SC/ST
Other castes
Total
Fully immunized Contraceptive
children
ever-users
(%)
(%)
85
69
83
76
57
61
(405)
(618)
74
84
73
85
64
55
(689)
(334)
78
83
80
83
59
58
(328)
(695)
(1,023)
82
79
80
84
80
81
61
57
59
PHC/SC=primary health center or subcenter; SC/ST=scheduled caste or scheduled tribe.
Findings
The data were first analyzed to assess the quality and coverage rates
of family welfare services in Ahmrdnagar District. I h(' analysis then
focused on whether those rates varied with clients' background char
acteristics and with the quality of services provided.
Coverage of Family Welfare Services
Coverage rates of family welfare services were found to be fairly high
in the study area. More than 80 percent of mothers had registered for
antenatal care, 81 percent of children 12-23 months of age had been
fully immunized, and about 59 percent of the respondents reported
using some method of contraception (Table 3.1). When we examined
those coverage rates against the clients' background variables, some
interesting differences emerged.
Registration rates for antenatal care were somewhat more, but
not consistently, related to clients' background characteristics,
whereas child immunization rates were somewhat less so. Antenatal
care registration was substantially higher among respondents living
in villages with a EHC or SC (85 percent) than among those living in
38
I
Quality of Services in Rural Maharashtra
more remote villages (69 percent); similar differences were evident
for full immunization (83 percent versus 76 percent). The next most
sensitive relationship was with mother's education, with literate
women reporting higher levels of antenatal care registration and full
immunization than illiterate women. Economic status and caste, how
ever, showed little effect on registration levels.
In the case of family planning use, the highest rates were found
among illiterate women and those living in non-PHC/SC villages.
Many literate women reported that they were practicing natural meth
ods, but those methods were not included in the estimation of the
coverage rates. Once again, no significant difference was observed in
family planning use rates by economic or social status.
The lower antenatal care registration in non-PHC/SC villages
was not due entirely to much higher proportions of illiterate women
living in those villages (52 percent compared with 33 percent in vil
lages with health facilities). Even after we controlled for education,
registration rates for antenatal care in PHC/SC villages were some
what higher than those in more remote villages.
ANMs reported that they found it difficult to explain the advan
tages of antenatal care to illiterate women. Although they had a little
less difficulty explaining the importance of child immunization, the
proportion of children fully immunized was significantly lower
among the children of illiterate mothers (73 percent) than among those
whose mothers were literate (85 percent).
Quality of the Service-delivery System
We next assessed the quality of the system for delivering family wel
fare services. During the survey interviews, respondents were asked
four questions about the delivery process: (1) Had they been visited
by a health worker during the previous three months? (2) If so, were
they satisfied with the amount of time the worker spent with them?
(3) Had the client been told about spacing methods? and (4) Had the
client been informed about the possible side effects of all methods
discussed? The percentages of affirmative answers to these questions
were used to construct an index of service quality. The overall index
of quality assessed in this fashion was found to be less than 50 per
cent, indicating considerable scope for improvement.
Nirmala Murthy
TABLE 3.2
Quality of service delivery, by clients’ background characteristics:
Ahmednagar District, Maharashtra, 1994
I&
I-j.-:
R■
I
f
1 .
-
(%)
(%)
(%)
_ ANM discussed
Spacing Side effects
Characteristic
(No.)
Residence
PHC/SC villages
Other villages
(673)
(350)
61
32
44
18
49
18
51
36
Mother’s education
Illiterate
Literate
(405)
(618)
45
56
30
39
37
42
38
51
Economic status
Poor
Not poor
(689)
(334)
51
53
34
37
40
41
43
50
Social status
SC/ST
Other castes
(328)
(695)
58
48
51
42
32
36
48
37
40
46
45
45
Total
K
ANM spent
5+ minutes
ANM
visited
(%)
(1.023)
ANM=auxiliary nurse-midwife; PHC/SC=primary health center or subcenter; SC/ST=scheduled caste
or scheduled tribe.
About 51 percent of the respondents reported that an ANM had
visited them during the previous three months (Table 3.2). ANMs
were expected to visit 50 households per day and to visit all houses
\ •
within their area once every month. It was possible to complete this
JR
task only if they spent less than five minutes at each house. The ANMs
p
were making only one-half of the expected number of visits, but they
J
were not necessarily spending more time in the homes they visited.
According to respondent women who had been recently visited, only
R
a minority of visits (36 percent) lasted for more than five minutes.
Nevertheless, more than 75 percent of the women who reported ANM
visits were satisfied with the amount of time the ANMs had spent
1■
with them (data not shown). Women sympathized with the ANMs,
Kt-?
IgO '. and many commented that the ANMs were required to visit too many
8ps ; houses, so it was understandable and acceptable that they did not
t:
1
S'?. ■’
i
i-
spend much time in each house, provided that their visits were regular.
Another aspect
------------------------------r-----------------------------------------------of the delivery
Jr
process
----------------------------------------------------------that the survey
J explored
—
fe ?
was whether women were given a choice of contraceptive methods
Bp;'
and whether they were told about possible side effects of all methf ods. The survey of ANMs revealed that most health workers were
reluctant to inform women about the possible side effects of contraiB^: ; ceptive methods, especially of sterilization. The workers believed that
?
Jl
1-
4U
Nirmala Murthy
Quality of Services in Rural Maharashtra
this information discouraged women from accepting any method.
Only a minority of acceptors of all methods (45 percent) reported that
they had been told about possible side effects of the method they were
adopting; this percentage was notably higher for IUD and pill users
(80 percent) than for sterilization acceptors.
When these service variables were analyzed against clients' back
ground characteristics, important differences were evident in all four
elements of the delivery process, especially with respect to place of resi
dence (non-PHC/SC villages versus villages with health facilities).
ANMs visited the remote villages less frequently, and in only a few
homes (18 percent) did they spend more than five minutes because, as
they explained to interviewers, they had little time at their disposal.
Nearly three times as many women in the PHC/SC villages were told
about spacing methods as in more remote villages (49 percent versus
18 percent). The ANMs explained that women living in remote villages
could not reach the health centers easily if they experienced side ef
fects from spacing methods. Moreover, the ANMs were not sure that
they could maintain a regular supply of oral contraceptives to those
women, and therefore they appeared to pursue a deliberate policy of
not promoting spacing methods in remote villages.
Another significant finding was that a higher percentage of
lower-caste families reported ANM visits than did families from other
castes. Interestingly, during the survey some lower-caste respondents
voiced complaints that because most ANMs belonged to higher castes,
they avoided visiting the houses of scheduled-caste and tribal fami
lies. The ANMs, however, denied any such bias on their part, and
the data support their contention. Nevertheless, they were more likely
both to visit literate women and to inform them about side effects
associated with contraceptive methods than to have such contact with
illiterate women. Although differences between poor and not-poor
women were not evident with respect to visitation, better-off women
were more likely than poor women to have received information on
side effects.
Technical Quality of Services
To assess the technical quality of family welfare services, we exam
ined six indicators. They were the proportions of clients who (1) had
41
TABLE 3.3
Selected indicators of the technical quality of family welfare services:
Ahmednagar District, Maharashtra, 1994
Indicator
I
i
t
lx
i ■
I
-
Percentage
Received complete antenatal checkup
46
Delivery attended by trained personnel
51
Child fully immunized
86
Began breastfeeding immediately
22
Experienced side effects from sterilization
39
Side effects treated at government center
47
received complete antenatal checkups; (2) had their deliveries at
tended by trained personnel; (3) had their children fully immunized;
(4) began breastfeeding immediately after delivery; (5) experienced
side effects from sterilization; and (6) received treatment for side ef
fects at the government centers. All six indicators were based on the
information provided by women during the survey.
For antenatal services, technical quality was defined as receiv
ing a complete range of checkups that included a urine test, blood
pressure check, abdominal examination, TT injection, and treatment
for anemia. Delivery by trained persons was another indicator used
for assessing the technical quality. Only about one-half of antenatal
cases met those two criteria: 46 percent of the women had received a
complete antenatal checkup and 51 percent had had their delivery
attended by a trained provider (Table 3.3). To assess the technical qual
ity of child immunizations, we examined the proportion of children
who were fully immunized against five childhood diseases. This was
86 percent, and only a few dropouts were attributable in part to the
health system's failure to supply vaccines (particularly measles vac
cine) or to adverse reactions to immunization.
We assessed the technical quality of family planning by the inci
dence of side effects reported among sterilization acceptors and the
percentage of women who had received treatment for side effects at
the government health centers. Approximately 39 percent of steril
ization acceptors reported side effects. Although the survey did not
probe the nature and severity of those side effects, nearly 70 percent
of the women who had experienced side effects reported taking medi
cal treatment for them, and almost half of them had gone to a gov
ernment health center for treatment. The proportion of women re-
42
Quality of Services in Rural Maharashtra
TABLE 3.4
Technical quality of MCH and family planning services, by clients’
background characteristics: Ahmednagar District, Maharashtra, 1994
Characteristic
Residence
PHC/SC villages
Other villages
Mother's education
Illiterate
Literate
Economic status
Poor
Not poor
Social status
SC/ST
Other castes
Total
DeliveryImmuni- Immediate
Antenatal by trained zation
breastcheckup
person coverage feeding
(N)
(%)
(%)
(%)
(%)
TABLE 3.5
Sources of MCH and family planning services, by village type:
Ahmednagar District, Maharashtra, 1994
Steriliz. Treated
side at govt,
effects center
(%)
(%)
(673)
(350)
53
28
59
29
87
74
27
10
40
36
51
39
(405)
(618)
34
52
33
60
75
88
15
26
40
38
45
49
(689)
(334)
40
56
43
63
81
87
18
29
38
39
47
48
24
21
36
40
39
47
47
47
(328)
(695)
(1,023)
52
43
46
59
46
51
87
82
86
22
Nirmala Murthy
MCH=maternal and child health; PHC/SC=primary health center or subcenter; SC/ST=scheduled
caste or scheduled tribe.
porting side effects of spacing methods was much lower (18 percent),
largely because those who suffered side effects were likely to have
already discontinued the method.
During the survey interviews, few respondents complained
about the quality of family planning services or about the absence of
follow-up care. More than 70 percent of the acceptors said they were
willing to recommend their method to friends or relatives, indicating
their confidence in the method. Even among those who reported side
effects, a majority said they would recommend their method to
friends. We interpreted this response to mean that the side effects
were generally not too severe.
We next examined the technical quality of services by client char
acteristics (Table 3.4). For five of the six indicators, the technical quality
of services was poor for clients living in remote villages and those
with no education. The only exception was sterilization side effects,
with somewhat fewer women from remote villages than from PHC/
SC villages reporting having experienced them, although this differ
ence was not significant. The coverage levels of antenatal services re
ceived by women living in remote villages remained significantly
lower, even after controlling for education.
PHC/SC villages
Government
Other villages
Private
Government
Private
Services
(%)___
(%)
(%)
(%)
Family planning
30
66
74
63
41
26
Institutional deliveries
70
66
34
Treatment of childhood
diarrhea and ARI
20
80
20
80
Antenatal care
34
37
59
ARI=acute respiratory infections; MCH=maternal and child health; PHC/SC=primary health center or
subcenter.
The ANMs attributed the quality differences between PHC/SC
villages and those without health facilities to the failure of illiterate
women to come to the health centers for checkups, suggesting that
such women did not appreciate the need for the services. However,
the ANMs did not mention that antenatal checkups were offered only at
the PHC clinics or at SCs with proper facilities. Women living in remote
villages had no easy access to these services. In addition, many women
from poor households were not able to come to the clinics because they
had to work. Therefore, even after controlling for the effects of educa
tion, we found that lack of time and access to the clinics appeared to
prevent women from receiving the full range of antenatal checkups.
The delivery of immunization services, in contrast, has improved
over the years, and these services are now available in each village
on a specified day of each month. This improvement was reflected in
immunization coverage rates, which showed no differences between
PHC/SC and other villages when corrected for the different propor
tions of educated mothers in those villages (data not shown). This
finding suggests that antenatal service providers should consider
adopting a delivery strategy similar to that for immunization services.
Satisfaction with Government Services
The survey data showed widespread use of private doctors for such
services as deliveries and family planning, in both PHC/SC and more
remote villages. The share of private services was also similar in both
types of villages (Table 3.5). These findings suggest that women went
I:
4
I
I
I
44
Nirmala Murthy
Quality of Services in Rural Maharashtra
TABLE 3.6
Client satisfaction with government and private services:
Ahmednagar District, Maharashtra, 1994
Percentage satisfied with
Government
Private
Criteria
Difference"
(%)
Tangibles
Clinic is neat and clean
Medicines are available
Responsiveness
Doctors pay attention
Don’t have to wait long
81
56
95
82
17
46
69
74
88
69
28
Reliability
Treatment is effective
Patient is properly examined
62
68
86
94
39
38
Empathy
Timing is convenient
Staff is friendly
68
74
87
90
28
22
Assurance
Doctor is available when needed
Questions are answered
64
75
87
94
36
25
a
Private - Government
Government
x 100
to private doctors not because government services were not acces
sible, but rather because they preferred the private services if they
could afford them.
When the women were asked how they had chosen their service
provider, the criterion mentioned most frequently (81 percent) was
"effective treatment or good experience in the past" (data not shown).
Other criteria mentioned were the availability of a doctor (48 percent),
proximity to home (35 percent), and affordable cost (15 percent). In
the opinion of most respondents (more than 80 percent), private prac
titioners met these criteria better than government doctors.
Several investigations of the quality of health services have found
that regardless of the type of service, clients use similar criteria to
evaluate service quality (Parasuraman and Zeithaml 1986). These are
tangibles (appearance of facilities, equipment, and personnel), respon
siveness (willingness to help and provide prompt service), reliability
(dependability and appropriateness of services), empathy (caring at
tention by service providers), and assurance (trust and confidence in
service providers). Although clients can directly assess service qual
ity by using these criteria, their satisfaction with a service depends
on how well the service performs as compared with an "ideal" serv
ice that the clients have experienced or know about.
I.
■
45
Because most village women in our sample looked upon private
services as ideal, we compared their perceptions of government and
private services to gauge the extent to which they were satisfied with
the government services. This exercise was carried out with a stan
dard measurement instrument called SERVQUAL (Parasuraman,
Zeithaml, and Barry 1988). It consists of 10 items representing the five
criteria of quality mentioned above. Respondents were asked to
specify how frequently those items were present in the government
and private services. Their tabulated responses are shown in Table 3.6.
On all items but one, the respondents rated the government serv
ices as inferior to the private services. The overall score for the gov
ernment services was 30 percent lower than that for the private services. But on some items the differences were much greater. We infer
that those items reflect significant areas of dissatisfaction with govemment services.
I
Sources of Dissatisfaction with
Government Services
ti
The largest differences in respondents' ratings of the government and
private-sector services were in the reliability criteria. Significantly
more women thought that private doctors examined them properly
and gave more effective treatment than they received from govern
ment doctors. The four items on which the difference between pri
vate and government ratings was more than 30 percent were avail
ability of medicines (46 percent difference), effective treatment (39
percent difference), proper examination of patients (38 percent dif
ference), and availability of doctors (36 percent difference).
A shortage of doctors was indeed a problem in the study area.
Although 14 medical officer positions were sanctioned for the block's
PHCs, only seven were filled at the time of the survey. All the PHCs
were functioning with one medical officer instead of two. Therefore,
the probability that a doctor would not be available to treat a patient
seeking care at a PHC was high because the medical officers had ad
ministrative duties as well as responsibility for treatment.
Government doctors were able to spend very little time with pa
tients. For example, during a four-hour period in the outpatient de
partment of one PHC, the average number of patients seen was about
50, with the result that the average amount of time available per pa-
-
L
I
I
I■
p ■
I
I
|
I
s
46
Nirmala Murthy
Quality of Services in Rural Maharashtra
bias toward poor or illiterate clients (Table 3.7). The only background
characteristic that showed significant differences was again place of
residence: Women from the PHC/SC villages rated all aspects of serv
ice more highly than did women from remote villages. It could be
that the health staff were more familiar with, and hence more cordial
toward, clients from the PHC/SC villages. We know that workers
were not able to spend much time in the remote villages because of
the distance and difficulty of traveling to them. Similarly, patients
who came to the PHCs or SCs from remote villages and did not find
a doctor in attendance were more likely to be disappointed with the
service than were those who came from nearby localities.
TABLE 3.7
Satisfaction with government services, by clients’ background
characteristics: Ahmednagar District, Maharashtra, 1994
Effective
treatment
Medicines
available
Examined
properly
Doctor
available
Characteristic
(No.)
(%)
(%)
(%)
(%)
Residence
PHC/SC villages
Other villages
(673)
(350)
60
50
58
49
68
58
66
54
Mother's education
Illiterate
Literate
(405)
(618)
54
59
58
53
63
67
64
62
Economic status
Poor
Not poor
(689)
(334)
54
62
54
57
65
67
62
63
(328)
(695)
(1,023)
55
57
56
56
55
55
69
63
65
65
61
62
Social status
SC/ST
Other castes
Total
:
■
I?
PHC/SC=primary health center or subcenter; SC/ST=scheduled caste or scheduled tribe.
tient was less than five minutes. Most of the PHC doctors did not
examine antenatal cases themselves, not even high-risk cases, but in
stead referred them to the ANMs.
The PHC doctors defended their actions by arguing that because
most patients came to the PHCs with only minor ailments, they did
not need lengthy examinations. Private doctors spent more time with
patients, they said, only to collect higher fees, whereas government
doctors provided care that was technically appropriate. But what the
PHC doctors considered appropriate treatment, clients often consid
ered inadequate or ineffective. The PHC doctors, they said, did not
examine them properly or give them good-quality medicines. Our
impression was that whereas private doctors were dispensing exces
sive and perhaps unnecessary drugs to impress patients, the govern
ment doctors were giving patients only a few tablets, usually enough
for only one day, to avoid wasting medicines. Thus there were large
gaps between what the PHC doctors considered to be appropriate treat
ment and what the patients expected from the government service.
We were also interested in learning whether clients' perceptions
of government services varied by client characteristics. Differences
in responses by educational level, economic status, and social status
were minor, suggesting that the PHC staff exhibited no systematic
4;
I
■
■
■
■
I-
R■
Summary and Conclusion
The data presented in this chapter suggest that the quality of the
government's family welfare services, both its technical aspects and
service delivery process, need considerable improvement. Greater at
tention needs to be paid not just to the provision of supplies and
equipment, but also to clients' perceptions and constraints.
Service quality is not a tangible product. Il is generated al the
time of service delivery, through a range of interactions between the
client and service provider. The degree of communication between
the two largely determines how favorably the client regards the serv
ice. Therefore, any barrier to that communication—such as the dis
tance between the client's home and the center, the client's inability
to understand the provider's message, or the provider not taking
enough time to communicate effectively—are detrimental to service
delivery quality. A strategy aimed at improving service quality needs
to take such barriers into account and develop approaches to ensure
maximum communication with clients. The strategy adopted for im
munization services in the study area, for example, seems to a con
siderable extent to have achieved this goal. Similar approaches are
needed to improve the quality of other services.
The three dimensions of service quality—process quality, tech
nical quality, and client satisfaction—have to be treated as related but
distinct entities. A worker spending less than five minutes during a
home visit may exhibit poor process quality, but the client may find
the length of the visit satisfactory. Similarly, a PHC doctor may pro-
48
Quality of Services in Rural Maharashtra
vide technically sound curative care, but patients may not be satis
fied with it. Therefore, while deciding on an intervention for improv
ing service quality, program managers must assess its potential im
pact upon on all three dimensions of quality.
4
References
Bruce, Judith. 1990. "Fundamental elements of the quality of care: A simple
framework," Studies in Family Planning 21(2): 61-91.
Jain, Anrudh K. 1992. "Definition and impact of quality," in Managing Quality of
Care in Population Programs, ed. Anrudh K. Jain. West Hartford: Kumarian
Press, pp. 10-19.
Parasuraman, A. and V. Zeithaml. 1986. "A conceptual model for service quality
and its implications for future research," Journal of Marketing 49: 41-50.
Parasuraman, A., V. Zeithaml, and L. Barry. 1988. "SERVQUAL: Multi-item scale
for measuring consumer perceptions of service quality," Journal of Retail
ing 64(1): 2-40.
Ramasundaram, S. 1994. "Quality of care in health and family welfare programme:
A service provider's perspective," paper presented at the Seminar on Quality
of Care, Gujarat Institute of Development Research, Ahmedabad, 2S-29 April.
Vera, Hernan. 1993. "The client's view of high-quality care in Santiago, Chile,"
Studies in Family Planning 24(1): 40-49.
Verma, Ravi K., T.K. Roy, and P.C. Saxena. 1994. Quality of Family Welfare Serv
ices and Care in Selected Indian Slates. Bombay (Mumbai): International In
stitute for Population Sciences.
Visaria, Leela and Pravin Visaria. 1990. "Quality of services and family plan
ning in Gujarat State," Working Paper No. 34. Ahmedabad: Gujarat Insti
tute of Development Research.
World Bank. 1995. India's Family Welfare Program: Towards a Reproductive and Child
Health Approach. Population and Human Resources Operations Division,
Report No. 14644-IN. South Asia Country Department II (Bhutan, India,
Nepal).
The Quality and Coverage of
Family Planning Services in
Uttar Pradesh:
Client Perspectives
M. E. KHAN, R. B. GUPTA, & BELLA C. PATEL
I
Experts are increasingly emphasizing the need to assess the quality
of family planning services from the users' perspective. It has there
fore become necessary to define the concept of quality and identify
measurable indicators (Bruce 1990). The conceptual framework pro
posed by Bruce and Jain (1991) has stimulated worldwide interest in
research on the quality of services provided by various cadres of health
and family planning providers.
In India researchers have only recently begun to show an inter
est in the quality of family planning services. As a result, few detailed
studies have been undertaken exclusively either to assess the quality
of services or to understand its influence upon the acceptance and
continuation of contraception. Although many demographic surveys
have collected information on the availability of contraceptives, cli
ent-provider contact, or the provision of follow-up services to accep
tors, the information is generally analyzed superficially within the
context of the overall functioning of the Family Welfare Programme.
During the past several years, however, a few focused studies have
used Bruce's framework, and several of them are included in the
present volume (see Chapters 2, 5, 6, 9,13, and 14).
The government of India has announced several important
changes in the strategy of the Family Welfare Programme. The new
strategy shifts the policy emphasis from achieving demographic goals
to meeting the reproductive needs of individual clients (GOI 1996).
!
Ir
I
J
■
4Q
50
Client Perspectives in Uttar Pradesh
The reproductive health of women has become the principal focus of
service delivery. Accordingly, family planning targets have been re
moved, and district-level planning has been proposed to make the
program more effective and client-oriented. These changes have re
inforced the importance placed upon the quality of services in the
government's new service-delivery strategy. The first step toward
improving program services is to document their current quality and
to identify major problems that should be addressed. The quality of
the Family Welfare Programme varies widely across India's vast and
diverse regions. Drawing upon a large data base, this chapter attempts
to assess the quality of family planning services provided in the north
ern Indian state of Uttar Pradesh.
The Setting
In area, Uttar Pradesh is the second largest state in India. It is also the
most populous, with a population in 1991 of 139 million, according
to the latest Indian census. Demographically it is one of the least ad
vanced states of India, with a high crude birth rate (36 per 1,000), a
high crude death rate (12 per 1,000), a high infant mortality rate (92
per 1,000), and a low contraceptive prevalence rate (20 percent). The
population of Uttar Pradesh grew by 25.5 percent between 1981 and 1991.
The state also lags behind most other states in social and eco
nomic development. In 1984, for example, 45 percent of its popula
tion lived below the poverty line, compared with 37 percent in the
country as a whole. During fiscal year 1985—86, per capita income was
estimated to be Rs598, as compared with a national average of Rs798.
Less than 20 percent of its population lived in urban areas, as com
pared with 26 percent for the country as a whole. Only 21 percent of
females aged 6 years old and above could read and write, compared
to the national average of 29 percent. These indicators also vary widely
within the state.
A number of recent studies reveal that health and family plan
ning services in Uttar Pradesh are of low quality, are poorly man
aged, and are often inaccessible to poor people (CORT 1997; HPS1995;
Khan and Gupta 1989; Khan and Patel 1994; ORG 1991; SIFPSA and
the Population Council 1994a; SIFPSA, USAID, and The EVALUATION Project 1996).
M. E. Khan • R. B. Gupta • Bella C. Patel
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51
Data
Data for the present study were drawn from a baseline survey un
dertaken in 16 districts of Uttar Pradesh by the State Innovations in
Family Planning Services Agency (SIFPSA) and the Population
Council between September 1993 and January 1994. Nine consul
tancy organizations were involved in the data collection and prepa
ration of the reports (Gupta and Talwar 1995). The baseline survey
covered three to four districts from each of the five geographic re
gions of the state (Hilly, Western, Central, Eastern, and Bundel
khand). A sample of 2,500 households was drawn from each dis
trict, and all ever-married women aged 13-49 years in the selected
households were interviewed by means of a structured question
naire. Details of the sampling procedures are given elsewhere
(SIFPSA and the Population Council 1994b). Altogether, 39,710
households were covered and 45,241 women were interviewed. Six
teen published reports from the survey provide detailed informa
tion on the maternal and child health (MCH) and family planning
programs in each district. They offer a wealth of information and
are methodologically comparable with data from the 1992-93 Na
tional Family Health Survey. For this chapter we have pooled the
data collected in the baseline survey and applied appropriate
weights to estimate results at the state level. Although the central
focus of the survey was not the quality of family planning services,
a limited but informative set of questions addressing clients' per
ceptions of the quality of family planning services was included and
is considered here.
Apart from household interviews, village information schedules
were also completed for all the villages in the study. The schedules
provide information on the availability of health and family planning
services from sources other than primary health centers (PHCs) and
subcenters. If the villages included in the study had government
health and family planning clinics, those clinics were also visited to
assess their facilities and resources, both human and physical. The
data provide valuable information on the functioning and accessibil
ity of the facilities. This chapter also draws liberally on data from other
studies, such as the PERFORM Survey (SIFPSA, USAID, and The
EVALUATION Project 1996).
i he Availability ot Contraceptives at
Subcenters and Other Public Clinics
TABLE 4.1
Availability of family welfare facilities at the subcenter level:
Rural Uttar Pradesh, 1993-94
In rural areas, subcenters are the main source of family planning serv
ices. The male and female staff posted at these facilities are expected
to conduct outreach by making home visits and providing services
to clients at their doorsteps. We sought to learn the extent to which
the quality of the facilities conformed to the established norm. Our
analysis presents a mixed picture.
In Uttar Pradesh each subcenter served, on average, a popula
tion of 4,706, which accords with the government's prescribed norm
of one subcenter per 5,000 population in the plains regions; however,
the population size varied from 3,000 to 6,500 (Table 4.1). At the time
of the study only 86 percent of the subcenters were staffed by auxil
iary nurse-midwives (ANMs). In other words, 14 percent of the
subcenters were nonfunctional. Only 52 percent of the subcenters had
male staff members in position. Most of the physical facilities were
in poor condition and had inadequate logistic support. Fewer than
20 percent of the subcenters functioned in their own buildings. The
I
remainder rented space—usually the veranda of a small house or a
tiny room—with no electricity or water supply. When a clinic was
not in session, the landlord used the room for living space. Provid
ing adequate health care in such facilities presents a serious challenge:
1 rivacy is difficult to maintain, lighting is inadequate, and poor sani
tation increases the risk of infection.
Many of the subcenters had no examination table and little equip
ment. In the subcenters that rented space, the facilities of most con
sisted merely of a wall cabinet containing some drugs and contra
ceptives. Any equipment and medicines were generally kept locked
in the cabinet and were rarely used during clinic hours.
The monthly rent officially approved by the government for the
subcenters is so low (Rs25-80) that subcenter staff cannot afford bet
ter facilities. The study found, however, that the subcenters had not
received even this small rental subsidy for the past two years. Ac
cording to one landlord, the subcenters were being allowed to func
tion in the hope that the accumulated rent would eventually be paid.
These observations are corroborated by a detailed situation analysis
done by the Population Council (1995) in two districts of Uttar Pradesh
and a large 1baseline survey conducted in 18 representative districts^^^ ^
of the state (SIFPSA,
SIFPSA, USAID, and The EVALUATION Project 199^?^4
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Indicator
Rural average
Average population per subcenter
4,706
Percentage of subcenters with
ANMs in position
Male health workers
Government building
IUD kits
ANMs trained in IUD insertion
86
52
17
57
56
Percentage of subcenters reporting regular supply of
IUDs
Oral contraceptives (pills)
Condoms
50
67
78
ANM=auxiliary nurse midwife; IUD=intrauterine device.
Substantial percentages of the subcenters reported irregular sup
plies of contraceptives. Supplies of intrauterine devices (IUDs) were
especially unreliable. Only one-half of the subcenters reported a regu
lar supply of IUDs and only 57 percent reported having IUD inser
tion kits. Although the situation was considerably better in the Hilly
and Bundelkhand regions of the state, it was the poorest in the east
ern region (data not shown). Several recent studies show that many
ANMs lack confidence about their ability to insert IUDs (ICMR1991;
Population Council 1995; see also Chapter 12). When all sources are
considered (public, private, nongovernmental organizations), contra
ceptives are available in 25-30 percent of the villages at most.
A discussion with medical officers-in-charge and other health
workers about the availability of other methods revealed that steril
ization services (mainly the female method of tubectomy) were avail
able mostly through organized camps and weekly clinics.1 They were
run with the help of doctors from the district headquarters, who had
the required equipment and support staff. If these special clinics did
not exist, female sterilization services would be largely unavailable
at the PHC level. In addition, most doctors posted at PHCs generally
have had no experience in performing vasectomies. Those who do
generally have not performed them for a long time, so the procedure
is rarely offered at camps or on sterilization days at the PHCs. The
number of vasectomies at the national level has dropped from 6.1 mil
lion in 1976-77 to fewer than 0.3 million in 1995. The availability of
IUD services at subcenters was also reported to be limited due to the
. shortage of IUDs or the lack of IUD insertion kits.
1
___________
06654
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54
Client Perspectives in Uttar Pradesh
TABLE 4.2
Clients’ contact with the Family Welfare Programme during the three
months prior to the interview: Rural Uttar Pradesh, 1993-94
TABLE 4.3
Findings from studies on clients’ contact with ANMs and other health
workers to discuss family planning: Rural Uttar Pradesh, 1971-95
■S
Percentage of women reporting contact
during three months prior to interview
Residence
Urban
Rural
Total
Home visit by
health worker
4
12
10
Visit to clinic by
respondent or
family member
17
14
15
Name or
description
of study
I
Total
contacts
Number
(in thousands)
21
26
25
(8,041)
KM’-
(21,380)
(29,421)
Nearly half (45 percent) of the 2,428 public facilities covered in
the 1995 PERFORM Survey reported having run out of contracep
tives at least once during the previous year. Only 14 percent of facili
ties offering sterilization services (PHCs and community health cen
ters) were equipped to provide such services, despite the fact that
sterilization is the most commonly used contraceptive method in In
dia (SIFPSA, USAID, and The EVALUATION Project 1996).
I
t
i
b
B ■
Clients' Contact with the
Family Welfare Programme
Clients can gain access to the government's Family Welfare
Programme through one of two means: by visiting clinics that offer
general health, MCH, or family planning services or through home
visits made by extension workers. As shown in Table 4.2, the extent
of contact between prospective clients and government health or fam
ily welfare staff is very low. Only 10 percent of the women reported
outreach visits by family welfare staff during the three months prior
to the interview. Similarly, only 15 percent of the women reported
that either they or a member of their family had sought help from a
public-sector clinic during the same period. Thus, only one-quarter
of the respondents reported recent contact with the Family Welfare
Programme. The level of contact in urban areas was no better than
that in rural areas.
District-level analysis of the survey data reveals wide variation
in the percentage of households that had recently received visits by
workers—from as low as 2 percent to as high as 50 percent. The me
dian value was only 10 percent, meaning that in one-half of the dis-
55
M. E. Khan • R. B. Gupta • Bella C. Patel
Area
covered
covered
Percentage
Sample
Sample of couples
Year of
size
size ever contacted study
Source
13.0 (males)
8.0 (females)
1971
Misra et al.
1982
330
7.8
1975
Khan 1979
1 district
1,000
7.0
1980
Kumar and
Sharma 1985
Postproject
survey of IPP
in UP
3 districts
NA
15.0
1983
Population
Centre 1984
Endline survey of
IPP in UP
Communication
needs assessment
in UP
3 districts in
eastern UP
3,000
23.8
1988
Khan and
6 districts
3,018
41.6
1990
Gupta 1989
ORG 1992
UP baseline survey
16 districts
45,241
9.5a
1993
SIFPSA and
the Population
Council 1995
PERFORM Survey
18 districts
45,277
7.0b
1995
SIFPSA, USAID,
and The
EVALUATION
Project 1996
Kanpur Study
Rural Allahad
Division
2,192
Family Planning
Among Muslims
Urban Kanpur
Study of maternity
and sterilization
wings
■
IPP=lndian Population Project; NA=data not available; UP=Uttar Pradesh.
8 Reference period six months; b Reference period three months.
Ig;.
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tricts of Uttar Pradesh, 10 percent of couples or fewer were visited by
the family welfare workers for educational or family planning pur
poses. The corresponding median value for clients' visits to the clin
ics was around 15 percent.
Table 4.3 suggests that there has been little improvement in the
outreach of health and family planning services in Uttar Pradesh over
the past two decades, despite a manifold increase in staff strength
and infrastructure. The 1971 Kanpur Study in five districts of eastern
Uttar Pradesh was one of the earliest efforts to analyze the functions
and outreach of the program (Misra et al. 1982). Of the 2,192 couples
interviewed in the study, only 13 percent of husbands and 8 percent
of wives reported that workers had ever visited them to discuss fam
ily planning. Similarly low levels of client-provider contact were re
ported in other studies conducted during the 1980s. The Uttar Pradesh
Baseline Survey and the PERFORM Survey, conducted in the 1990s,
56
Client Perspectives in Uttar Pradesh
M. E. Khan • R. B. Gupta • Bella C. Patel
TABLE 4.4
Percentage of women receiving outreach services
during the three months prior to the interview,
classified by workers’ sex: Rural Uttar Pradesh, 1993-94
Percentage
of all women
Any worker
9^5
Female worker only
7.1
74.3
Male worker only
0.9
Male and female worker
1.5
9.5
16.2
(2,800)
(29,421)
• With the increasing emphasis of the Family Welfare Pro
gramme on female clients, the utility of male workers for fam
ily planning work, as perceived by program managers, has
declined. As a result, positions for male workers that have
fallen vacant due to workers' retirement or for other reasons
have generally remained unfilled. Today almost half of the
male workers' positions are vacant, and the number of male
.
workers is almost one-half of the prescribed ratio of one male
worker per 5,000 population.
• Earlier, each male worker was expected to organize small
meetings of male opinion leaders at the village level to edu
cate them about contraception and available family planning
■B' T
methods. However, with the increasing emphasis on women
as the target of the program, these orientation sessions have
ceased, and in the process an opportunity to educate and in
volve men in the program has been lost.
Today most male workers are at least 45 years of age. A recent
in-depth study of 73 male workers from two districts of Uttar Pradesh
found that most believed that vasectomy could not become as preva
lent as it used to be (Gupta et al. 1997). Further, because of their greater
age, they found it embarrassing to contact and motivate young couples
to use condoms. As some of them put it, "They are as old as my sons.
Our sanskriti [culture] does not allow free discussion on such issues
with youths and young couples."
fcl
Workers
(Total estimated no., in thousands)
57
KI ■
Percentage
of those visited
100.0
found that the outreach program still served fewer than 10 percent of
the eligible couples of Uttar Pradesh on a regular basis. According to
the PERFORM Survey, only 7 percent of women were contacted by
any provider during the six months prior to the interview (SIFPSA
and the Population Council 1994a; SIFPSA, USAID, and The EVALU
ATION Project 1996).
An analysis of the providers by sex shows that the limited out
reach work currently being carried out is done mainly by female work
ers, or ANMs (Table 4.4). Seven percent of all households were vis
ited by only female workers, 1.5 percent by both male and female
workers, and 0.9 percent by only male workers. Among the subsample
of women who reported that they had been contacted, 74 percent were
contacted by only female workers, nearly 10 percent by only male
workers, and 16 percent by both. During the early 1970s male work
ers were more involved than they are today in promoting family plan
ning, and this was reflected in the prevalence of vasectomy. Male
workers now appear to play only a marginal role in the Family Weifare Programme.
There are several reasons for the shift from male to female workers:
• A shift in program emphasis from vasectomy to tubectomy
meant that women with three or more children became the
main target for counseling and motivational efforts. In the cul
tural setting of Uttar Pradesh, it is difficult for male workers
to talk to rural women about family planning. Male workers
have therefore been shifted from family planning activities to
health program activities such as malaria control, chlorinization
of wells, school health programs, and epidemic prevention.
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Selectivity in Outreach Visits
■IK
fc.
Sr:
Within this context of extremely low levels of outreach, we found evi
dence of considerable selectivity in outreach visits by female work
ers (Table 4.5). Although there was little difference among respon
dents of different religious or caste affiliations in the probability of
having been recently visited by a worker, other associations were
slightly more pronounced. Women with no living children or sons
were less likely than others to have been recently contacted. Simi
larly, women with no formal education were more likely than highly
educated women (those with 11 or more years of schooling) to have
reported a recent contact. Lastly, women residing in villages where
the PHC or subcenter was located were more likely to receive visits
58
M. E. Khan • R. B. Gupta • Bella C. Patel
Client Perspectives in Uttar Pradesh
TABLE 4.6
Purpose of health worker’s last visit, as perceived
by women receiving outreach services during
the three months prior to the interview: Rural Uttar Pradesh, 1993-94
TABLE 4.5
Percentage of women receiving outreach services
during the three months prior to the interview,
classified by client characteristics: Rural Uttar Pradesh, 1993-94
Characteristic
Religion
Hindu
Muslim
Other
Percentage
of women
Estimated no.
(in thousands)
10
9
14
24,558
4,474
389
Caste
Scheduled caste/tribe
Lower caste
High-caste Hindu
Non-Hindu
Parity
0
1
2
3+
6
10
9
11
3,448
3,684
4,292
17,997
No. of living sons
0
1
2+
8
10
10
5,355
9,002
15,064
Wife's education
No education
Up to primary (1-5 years)
Middle (6-8 years)
Matriculated (9-10 years)
11 +
11
10
9
8
7
20,746
2,930
2,209
1,477
2,059
Residence
Village with PHC/SC
Remote village
13
9
10
11
9
9
6,677
8,849
9,070
4,825
9,503
19,918
Type of health worker (%)
Purpose
I
1=
I
ik
I
!
PHC/SC=primary health center or subcenter.
-
from the ANM than were women who lived in more remote villages.
These results suggest that, in their efforts to motivate couples for ster
ilization, workers tended to focus on illiterate and presumably poorer
women, who often had larger families and were more likely to be
easily influenced by sterilization incentives than were women with
more education. It should be emphasized, however, that the level of
outreach visitation by female providers was extremely low for all cli
ents, regardless of client characteristics or place of residence.
It is noteworthy that many of the women surveyed did not be
lieve that workers concentrated their efforts, at least in providing an
tenatal care, on poor and lower-caste women. About half (45 percent)
of all women believed that high-caste ANMs did not like to attend
1
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ANM or LHV
Male worker
Ail workers
Child immunization
54
37
53
Antenatal care
Motivation for sterilization
18
10
17
12
11
12
Malaria/blood collection
6
29
9
Follow-up
6
3
6
Postnatal care
Delivery assistance
6
3
6
2
Motivation for spacing method
5
4
5
5
4
Contraceptive supply or resupply
2
4
2
Unknown
3
4
3
Other
10
11
10
(2,485)
(315)
(2,800)
(Estimated no. of eligible women
contacted by workers in last
3 months, in thousands)
Note: Percentages may exceed 100 because of multiple responses.
ANM=auxiliary nurse-midwife; LHV=lady health visitor.
the deliveries of scheduled-caste women. The same percentage of
women believed that workers favored rich families and neglected poor
ones. Conversely, one-third of all women believed that high-caste
women preferred not to receive antenatal and postnatal care from
lower-caste ANMs.
A survey question about the purpose for which the workers con
tacted the women revealed that, in the case of female workers, a ma
jority of respondents (54 percent) thought the main purpose was to
immunize children (Table 4.6). Eighteen percent and 6 percent, re
spectively, thought it was to provide antenatal or postnatal care. Only
about one-fourth of visited women believed female workers focused
primarily upon family planning services such as motivation for ster
ilization (12 percent), motivation for nonpermanent methods (4 per
cent), contraceptive supply or resupply (2 percent), or follow-up of
sterilized clients (6 percent). In the case of male workers, apart from
immunizing children (mentioned by 37 percent of contacted women),
the perceived main purpose of contacting clients was to collect ma
laria slides (29 percent). In fact, malaria blood collection was the only
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60
Client Perspectives in Uttar Pradesh
area in which male workers were considered to be much more active
than female workers. As with perceptions of female workers' main
purpose, only about a quarter of respondents thought that family plan
ning services (motivation for sterilization, motivation for spacing
methods, supply of contraceptives, or follow-up) were male work
ers' main purpose. It would appear from these responses that all work
ers, male and female, place less emphasis on family planning work
than on other duties, and that low family planning service levels by
male workers are in part a function of the low level of male worker
outreach contact.
The differences in perceived purposes of contact with clients made
by male and female workers reflect actual differences in job respon
sibilities between the two types of workers. Given that female work
ers are responsible for most MCH and family planning outreach work,
the data in the subsequent tables of this chapter (with the exception
of one item in Table 4.12) refer only to contact with female workers.
TABLE 4.7
Quality of information and counseling given to prospective clients
about specific methods: Rural Uttar Pradesh, 1993-94
■
Information or counseling
I
| ::
If
Percentage informed
about method3
Percentage given information
about method6
Advantages only
Disadvantages only
Both
Neither
Total
Vasectomy Tubectomy
IUD
Pills
Condoms
33
78
35
42
36
71
2
17
10
100
67
3
22
8
100
56
3
28
13
100
61
3
26
13
100
68
2
20
10
100
88
87
85
91
86
I
Percentage told
how to use method
h
IUD=intrauterine device.
a Percentage is based upon those who were informed about a family planning method (estimated no.=
2,757,000); b Percentage is based upon those who were informed about the method.
I
b
t’
|
Quality of Services Provided
The Family Welfare Programme is expected to provide a 'variety
’
of
contraceptives, information about the contraceptives, checkups of pro
spective acceptors before offering them a method, and follow-up vis
its by paramedical staff. We analyzed respondents' answers to the
survey questions in an effort to evaluate these aspects of the program.
fI' ■r
Family Planning Information and
Method Choice
I
As we have already noted, few of the women contacted by family
welfare workers were given information on contraceptives. Further,
the Family Welfare Programme, with its primary emphasis upon ster
ilization, has clearly skewed workers' focus in favor of female steril
ization. Most women (78 percent) were informed about female steril
ization, whereas only 33-42 percent were informed about other
contraceptive methods (Table 4.7). These findings are corroborated
by a number of other studies (CORT 1992,1995a, 1995b, 1995c, 1996a
1996b; ICMR 1988, 1991; UPS 1995; Khan and Ghosh 1985; Khan and
Patel 1994; SRI 1992). In the 1991 ICMR study, only 18 percent of the
ANMs observed in clinics provided information about oral contra
61
M. E. Khan • R. B. Gupta • Bella C. Patel
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II
ceptives and only 27 percent mentioned condoms, whereas 62 per
cent mentioned sterilization and 57 percent provided information on
the IUD. A separate study from Orissa, Bihar, and Gujarat found that
out of 1,197 acceptors from various government clinics, only 12 per
cent were informed about more than one method, only 16 percent
were informed about the effectiveness of the contraceptive, and less
than 1 percent were informed about possible side effects (Khan, Patel,
and Chandrasekhar 1993; see also Chapter 12).
Similarly, even those who were informed about specific family
planning methods were often not given complete information. This
is evident from our finding that regardless of the method, only about
one of four women with whom a method was discussed was told
about the method's advantages and disadvantages (Table 4.7). For
instance, only about 22 percent of the women who were told about
tubectomy were informed about both the advantages and the disad
vantages of the method. Only the advantages of the methods were
mentioned in 56-71 percent of the cases. The reason could be that the
workers themselves possessed limited knowledge about the meth
ods (Population Council 1995), or that they feared that once clients
were informed about possible side effects of a method, they would
not accept it. Although a majority of workers understand the desir
ability of disclosing the disadvantages as well as the advantages to
their prospective clients, the pressure they feel to achieve their fam
ily planning targets may discourage them from being candid about
TABLE 4.8
Percentage of clients reporting that workers insisted upon
a particular method: Rural Uttar Pradesh, 1993-94
Measure
Of those who were
contacted by a worker,
percentage reporting
insistence upon a
specific method
Of those reporting
insistence upon a
specific method,
percentage mentioning
recommended method
M. E. Khan • R. B. Gupta • Bella C. Patel
Client Perspectives in Uttar Pradesh
62
Vasectomy Tubectomy
2
45
IUD Pills
7
5
I
Number (in
Condoms thousands)
4
(2,757)
71
11
8
6
♦>
r
Measure
®
Amount of time spent by worker during last visit
Not enough
As needed
46
54
'•
II
i
Was client satisfied with assistance provided during the visit?
Yes
Somewhat
No
67
25
8
Were client's questions answered?
Yes
Only partially
No
69
17
14
Would client like the worker to revisit?
Very much
Somewhat
Not at all
66
29
5
(Estimated no. of women, in thousands)
(2,425)
(1.737)
Note: Percentages in second row do not add to 100 because of rounding.
IUD=intrauterine device.
the disadvantages of the various methods (see Chapter 12). Even so,
although about 10 percent of the clients were merely told of a method
without being given any details (either its advantages or disadvan
tages), a few (2-3 percent) were told only about the disadvantages of
a particular method. It is possible that workers described the disad
vantages of one method to persuade the client to accept another. Most
of the women (85-91 percent) who were informed about a specific
method were also told how to use it.
According to the women we surveyed, in addition to the lim
ited information that workers gave clients about most contraceptives,
some workers insisted that their clients adopt sterilization, another
sign that workers felt pressured to achieve sterilization targets (Table
4.8). For example, 63 percent of the women reported that service pro
viders insisted they adopt a particular method, and a majority of them
reported that this pressure was to adopt sterilization (45 percent of
all women contacted by the workers and 71 percent of those who re
ported insistence by the workers for a particular method). Elsewhere
we show that workers, under pressure to achieve their sterilization
targets, tend to approach those women who have several children
and at least one son, considering them the best prospects for steril
ization (see Chapter 12). Among the women we surveyed, young
women, those with two or fewer children, and recently married
couples were rarely encouraged by workers to use contraception. This
indicates that outreach visitation efforts are skewed toward high-par
ity couples. Other studies have found a similar lack of interest by work-
--------------------------------------------------------------
a
f
3
TABLE 4.9
Quality of client-provider interactions during last visit:
Rural Uttar Pradesh, 1993-94
I
wIr
I
I
I
1iIB
i
Ii
I
Percentage
ers in counseling young or newly married couples about family plan
ning (SIFPSA and the Population Council 1994b).
The women we surveyed had a generally positive assessment of
the outreach visits by female field workers. More than two-thirds (69
percent) reported that their queries were fully answered, and 67 per
cent reported being satisfied with the services they had received (Table
4.9). Nevertheless, only 54 percent of the subsample of women who
were visited by female workers were satisfied with the amount of
time the workers had spent with them. Two-thirds expressed a strong
desire to have the workers revisit them.
Quality of Care for Method Acceptors
p
fr'
I?.
r
II
I
|R •
The satisfaction of family planning acceptors seems to depend upon
the quality of services they receive at the time of acceptance and the
follow-up care they receive if they experience complications. To assess the technical quality of services provided to clients, our survey
asked each sterilization or IUD acceptor questions related to the physi
cal examinations and tests they had received before accepting the
method.
Among current users of contraception, 8 out of every 10 women
electing sterilization were asked about their medical history prior to
undergoing the procedure, but only 7 out of 10 had their blood pres-
64
Client Perspectives in Uttar Pradesh
M. E. Khan • R. B. Gupta • Bella C. Patel
TABLE 4.10
Examinations and tests received by tubectomy and IUD acceptors
prior to acceptance: Rural Uttar Pradesh, 1993-94
Measure
Sterilization
Percentage of acceptors in sample
Type of examination or test (%)
Medical history taken before sterilization
Blood-pressure test
Vaginal examination
Breast examination
Menstruation status ascertained
(No. of current users, in thousands)
65
TABLE 4.12
Postacceptance follow-up and incidence of complications:
Rural Uttar Pradesh, 1993-94
Measure
IUD
14.9
1.5
81
70
49
46
70
(4,377)
66
40
38
24
63
(453)
1
K; _
g
IUD=intrauterine device.
Source: SIFPSA and The Population Council 1994a.
II
TABLE 4.11
Percentage of sterilized women and IUD acceptors willing to recommend
the method to others: Rural Uttar Pradesh, 1993-94
Method accepted
Rural
Urban
Total
Sterilization
IUD
42
42
39
39
51
37
45
38
lllll
fl- r--''
I
?
Ehi''
I
>
Percentage experiencing postacceptance
complications®
Sepsis
Pain in groin
Abdominal pain
Backache
Weakness
Excessive bleeding
White discharge
Loss of sexual desire
Other
■a'
■
I
RR
Tubectomy
IUD
6
6
1
18
4
14
3
0
3
36
5
24
47
3
30
1
20
23
21
I
Percentage of those reporting problems
who received help from any worker
i
IUD=intrauterine device.
sure measured and only 15 percent were subject to any examination
(Table 4.10). Seven out of 10 were asked for the details of their men
strual cycle. Vaginal and breast examinations were carried out in
slightly less than one-half of the cases. The survey did not include
questions about urine and blood tests, but observations made during
sterilization camps and clinic days indicated that both these tests were
generally carried out on each woman. However, the observers also
noticed that even if the women had hemoglobin levels lower than
required, they were marked "normal" and were approved for a tubec
tomy. These findings indicate that complete screening was not con
ducted before sterilization. Other studies on the quality of services
provided in sterilization camps in Uttar Pradesh, as well as in other
states, have reached the same conclusion (Parveen 1995; see also Chap
ters 13, 14, and 15). Only 1.5 percent of IUD acceptors were exam
ined or tested before accepting the device. The most common exami
nations were medical history, followed by ascertainment of
menstruation status, and then blood-pressure test.
To assess the extent of the satisfaction with the services provided,
each
-------sterilization
or IUD acceptor was asked whether she was will-
Percentage of acceptors receiving follow-up
visit(s) within one month
Visits from male workers
Visits from female workers
Vasectomy
Number of acceptors (in thousands)
------------------------------------- -
5
5
11
8
17
6
1
3
6
4
26
330
25
4,377
29
453
21
IUD=intrauterine device.
■ Multiple complications were reported.
ing to recommend the method to other women. Only 45 percent of
sterilized women and only 38 percent of IUD acceptors expressed a
—o------------------------------------------------------willingness
to recommend the method to other................
potential clients (Table
4.11). This indicates that more than one-half of the sterilization and
IUD acceptors were dissatisfied with the method or fthe
1----'
services
they
had received.
Postacceptance Follow-up and
Complications
AS
i-S'
Ipte'
■
iBt-
Information on follow-up assistance received from providers and
postacceptance complications faced by the acceptors also indicates
significant gaps in the quality and continuity of services. For instance,
only 6 percent of the men and 18 percent of the women who had un
dergone sterilization received a follow-up visit by health workers
within a month of the procedure (Table 4.12). This percentage was
even lower in the case of IUD acceptors (3 percent). These findings
assume added significance in light of the fact that a substantial pro
portion of the acceptors of vasectomy (36 percent), tubectomy (47 per
cent), and the IUD (30 percent) reported that they developed
ti;
66
Client Perspectives in Uttar Pradesh
postacceptance complications. Pain at the site of the operation, back
ache, weakness, and excessive bleeding were the most frequently men
tioned postacceptance complications. The study also shows that only
about one-fourth (25-29 percent) of those who reported complications
received assistance from any health worker.
Ninety-five percent of those IUD acceptors who suffered from
postinsertion problems had the IUD removed within a month (data
not shown). In the absence of detailed data on screening procedures
or technical competence of the workers who inserted the device, it is
difficult to comment on the quality of services provided. However,
the finding that about one-third of all IUD acceptors developed com
plications and had the device removed within a month of insertion
reflects poorly on the quality of services. Qualitative studies show
that a majority of ANMs lack the confidence to insert an IUD. More
over, most ANMs do not screen clients for possible reproductive tract
infections because they are more interested in meeting their IUD targets
(see Chapter 12). In a recent study conducted in the districts of Sitapur
and Jhansi in Uttar Pradesh, several ANMs expressed a need for practi
cal training in the screening of IUD cases and IUD insertion (CORT 1997).
M. E. Khan • R. B. Gupta • Bella C. Patel
K
I
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p?-’
fe'
H
Summary and Conclusion
The current study reveals that access to family planning services, par
ticularly in remote villages, is a major problem in Uttar Pradesh. De
spite a manifold increase in the number of field workers during the
past two decades, the coverage of the Family Welfare Programme
remains extremely low. With increasing emphasis on women as tar
gets of the program, the role of male workers as family planning ex
tension workers has been almost eliminated. With no new appoint
ments, almost half of the male workers' positions are vacant. This
trend needs to be reversed if the recent interest of program adminis
trators in involving men in reproductive health and contraception is
to be vigorously pursued.
Our findings indicate that during their extension work the ANMs
concentrate mainly on female sterilization. The quality of counseling
is generally poor. Workers provide incomplete information about
most methods, and the positive aspects of the method suggested are
emphasized to motivate the couples to accept it. Postacceptance fol-
j
is?
III'
p
It.
Hl
■■■:■
low-up is also poor. Given the high level of postacceptance compli
cations, the lack of proper follow-up contributes to negative percep
tions of the program. These perceptions are reflected in the finding
that less than one-half of the acceptors of sterilization and IUDs said
that they would recommend their method to other potential users.
Despite these shortcomings, the limited number of women who
received visits from the ANMs held a generally positive view of the
workers, were satisfied with the amount of time the ANMs had spent
with them, and wished that the ANMs would visit them again. This
encouraging result suggests that the program should increase its out
reach efforts.
Observations from the field and other studies indicate a number
of programmatic constraints that have a direct bearing on outreach
activities and the quality of services provided by the Family Welfare
Programme. The prime ones include inadequate resource allocation,
which leads to poor logistic support; lack of supervision and account
ability; lack of attention to the quality of services by those monitor
ing the program; and lack of competence among the workers, particularly in screening cases, inserting IUDs, and counseling clients.
An inadequate communication network also contributes to the poor
mobility and outreach of ANMs.
Various studies show that many program managers are well
aware of these limitations but are unable to address them effectively.
This is partly because of the bureaucratic inertia and hurdles they
face when trying to change the system and partly because of the lack
of resources from which the public clinics perpetually suffer. Unless
both these aspects are openly discussed and seriously addressed, it
will be difficult to institutionalize quality maintenance within the
■ present public health system.
-
r
?
.
Note
1
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67
These camps and clinics are usually organized during the months of Octo
ber through March so as to achieve family planning targets in time for the
annual assessment by higher authorities.
References
Bruce, Judith. 1990. "Fundamental elements of the quality of care: A simple
framework," Shidies in Family Planning 21(2): 61-91.
68
M. E. Khan • R. B. Gupta • Bella C. Patel
Client Perspectives in Uttar Pradesh
Bruce, Judith and Anrudh K. Jain. 1991. "Improving the quality of care through
operations research," in Operations Research: Helping Family Planning
Programmes Work Better, ed. Myrna Seidman and Marjorie Hom. New York:
John Wiley-Liss, pp. 259-282.
Centre for Operations Research and Training (CORT). 1992. Use of Risk Approach
in Comprehensive MCH Care: An ICMR Multi-centric Study: Final Evaluation.
Baroda: CORT.
--------- . 1995a. Small Family by Choice: Family Planning Programme in Madhya
Pradesh: Baseline Survey, Bhopal. Baroda: CORT.
--------- . 1995b. Small Family by Choice: Family Planning Programme in Madhya
Pradesh: Baseline Survey, Sagar. Baroda: CORT.
--------- . 1995c. Small Family by Choice: Family Planning Programme in Madhya
Pradesh: Baseline Survey, Vidisha. Baroda: CORT.
--------- . 1996a. Family Welfare Program in Bihar: A Baseline Survey, Gaya. Baroda:
CORT.
--------- . 1996b. Family Welfare Program in Bihar: A Baseline Survey, Nawada. Baroda:
CORT.
--------- . 1997. Training Need Assessment ofANMs in Uttar Pradesh. Baroda: CORT.
Government of India (GOI). 1996. Model Plan for District Based Pilot/Sub-projects
of Reproductive and Child Health (RCH). New Delhi: Ministry of Health and
Family Welfare.
Gupta, R.B., M.E. Khan, Bella C. Patel, and Nazir Haider. 1997. Promotional Ef
forts: Male Basic Health Workers' Perceptions from Two Districts of Uttar Pradesh.
New Delhi: Population Council.
Gupta, R.B. and P.P. Taiwar. 1995. Dissemination Workshops on Programme Impli
cations of Baseline Surveys in 15 Districts of Uttar Pradesh. New Delhi: Popu
lation Council.
Indian Council of Medical Research (ICMR). 1988. Utilization of Health and Fam
ily Planning Services in Bihar, Gujarat, and Kerala: A Task Force Study. New
Delhi: ICMR
--------- . 1991. Evaluation of Quality of Family Welfare Services at Primary Health Cen
tre Level: An ICMR Task Force Study. New Delhi: ICMR.
International Institute for Population Sciences (UPS). 1995. National Family Health
Survey (MCH and Family Planning): India, 1992-93. Bombay (Mumbai): UPS.
Khan, M.E. 1979. Family Planning Among Muslims in India: A Study of the Reproductive
Behaviour ofMuslims in an Urban Setting. New Delhi: Manohar Publications.
Khan, M.E. and Dastidar S.K. Ghosh. 1985. Women's Perspective and Family Plan
ning Programme. Baroda: Operations Research Group.
Khan, M.E. and R.B. Gupta. 1989. Role of Health Delivery Services in Acceptance of
Family Planning in Uttar Pradesh. Baroda: Operations Research Group.
Khan, M.E. and Bella C. Patel. 1994. "The state of family planning in Uttar
Pradesh, India: A literature synthesis," International Quarterly of Commu
nity Health Education 14(1).
Khan, M.E., Bella C. Patel, and R. Chandrasekhar. 1993. "Abortion acceptors in
India: Observations from a prospective study," in [Proceedings of the] Inter
national Population Conference, IUSSP, vol. 1, Montreal, pp. 253-268.
Kumar, A. and L. Sharma. 1985. Demographic, Health and Family Welfare Studies
of the Population. Lucknow: Population Centre.
Misra, B.D., George B. Simmons, Ali Ashraf, and Ruth S. Simmons. 1982. Organ
ization for Change. New Delhi: Radiant Publishers.
R
I
I£
i
i
i.
• g
t.
69
Operations Research Group (ORG). 1991. Family Planning Practices in India: Third
All-India Survey. Baroda: ORG.
--------- . 1992. Communication Need Assessment in Family Welfare Programme: Study
of Six Western Districts in Uttar Pradesh. Baroda: ORG.
Parveen, S. 1995. "Quality of care in sterilisation in rural Bihar: A qualitative
approach," paper presented at the National Workshop on Operations Re
search for Improving Quality of Services, sponsored by the Population
Council, Bangalore, 24-26 May.
Population Centre. 1984. Fertility and Family Planning in Rural Areas: A Post-Project
Survey in the Area of First India Population Project. Report Series. Lucknow:
Population Centre.
Population Council. 1995. Situation Analysis of Family Welfare Programme in Agra
and Sitapur Districts of Uttar Pradesh. New Delhi: Population Council.
State Innovations in Family Planning Services Agency (SIFPSA) and the Popu
lation Council. 1994a. Baseline Survey in Sixteen Districts of Uttar Pradesh.
Lucknow and New Delhi: SIFPSA and the Population Council
--------- . 1994b. District Level Baseline Survey of Family Planning Programme in Uttar
Pradesh. (15 volumes, one for each study district: Sitapur, Gonda,
Gorakhpur, Rampur, Shahjahanpur, Jhansi, Lalitpur, Jalaun, Pithoragarh,
Nainital, Tehri Garhwal, Meerut, Ghaziabad, Jaunpur, and Kanpur).
Lucknow and New Delhi: SIFPSA and the Population Council.
--------- . 1995. Baseline Survey of Family Planning Programme in Agra, Uttar Pradesh
New Delhi: SIFPSA.
State Innovations in Family Planning Services Agency (SIFPSA), United States
Agency for International Development (USAID), and The EVALUATION
Project. 1996. Performance Indicators for the Innovations in Family Planning
Services Project: 1995 PERFORM Survey. Uttar Pradesh State Seminar Re
port. Lucknow: SIFPSA.
Survey Research Institute (SRI). 1992. Proceedings of Workshop on Alternative Approaclus
to the Delivery of Family Planning Services in Uttar Pradesh. New Delhi: SRI.
I
T. K. Sundari Ravindran
s ■
5
Rural Women's Experiences
with Family Welfare Services
in Tamil Nadu
rft:
U;
S
T. K. Sundari Ravindran
1
The quality of care in family planning service delivery and, more re
cently, in the delivery of reproductive health services, has come to be
recognized as one of the major issues facing program planners, man
agers, and policymakers. A major portion of the growing body of lit
erature on this subject focuses on users' perspectives, which are
known to affect significantly the demand for family planning services.
Methods used to gather information on this aspect of the quality of
care include structured interviews (usually in the form of client exit
surveys), focus-group discussions, and the "mystery client" technique.
One of three approaches is usually employed to involve users in the
assessment process. Each has conceptual and methodological difficulties.
The first is to begin with a set of indicators of the benefits that
clients should receive from a service provider (e.g., complete infor
mation, privacy, and follow-up care) and to ascertain from clients'
responses whether the clients have received them. For example, the
international nongovernmental organization CARE, which provides
family planning services in India, involves clients in assessing its serv
ices. It asks each client:
• whether she received a family planning method, whether she
wanted it, whether she is satisfied with it, and whether she
can explain how to use the method;
• whether the location was convenient, clean, and affordable;
whether it had adequate privacy; and whether the waiting time
was acceptable; and
II
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s
v-
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70
71
• whether the provider was polite, allowed her to ask questions,
and allowed her adequate consulting time; and whether she
felt comfortable during the procedure (McGinn 1993).
The limitation of using a set of predetermined indicators is that
they may not tell us what clients themselves consider to be impor
tant aspects of service delivery or what, in their view, constitutes the
difference between poor service quality and good or high quality.
A second approach asks clients open-ended questions to ascer
tain whether they perceive the services received to be satisfactory.
Interpreting answers to such questions is difficult because each cli
ent may have a different yardstick for measuring the service. The same
package of services found unacceptable by one client may be perfectly
acceptable to another. We have no way of knowing whether differ
ences in responses are due to differences in service quality per se or
to differences in client characteristics. Ratings of satisfaction or dis
satisfaction may result from low or unrealistically high expectations
on the part of clients rather than from an objective assessment of the
services.
Clients expectations are likely to be influenced by their socio
economic and educational status, self-image, prior experience with
health services, and knowledge of and attitude toward various con
traceptive methods. For example, some clients may demand to be
served only by doctors, not paramedics, or insist upon having un
necessary laboratory tests, based upon experiences they have had in
other service-delivery outlets. At the other extreme, we found that
clients in one family planning clinic were being asked to remove their
blouses, in full view of other clients, in order to receive shots of DepoProvera in their upper arms. When questioned about their satisfac
tion with the services, the women expressed a high level of satisfac
tion, mentioning as reasons the length of time spent by the family
planning worker with them, the kindness shown, and the prompt
ness of the service. Clients with a greater concern about privacy would
have been extremely uncomfortable and might have decided not to
avail themselves of the clinic's services.
Users assessments may also be based on incomplete information.
Many clients may not know what the service-delivery package ought
to consist of. If they know about only one contraceptive method, they
will not complain if they do not receive information on all methods.
i
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72
Rural Women's Experiences in Tamil Nadu
The third approach entails developing indicators of the quality
of services on the basis of how users view those services. This ap
proach was used in a study conducted at a family planning and ma
ternal and infant care clinic in Santiago, Chile (Vera 1993). Clients at
the clinic defined high-quality care as "being treated like a human
being." Other desirable elements of care they identified were cleanli
ness, promptness, availability of service, time made available for con
sultation, learning opportunities for themselves and their partners,
and cordial treatment. Here again we run into the issue of subjectiv
ity: The list may have been different if the women had belonged to a
socioeconomic stratum in which cordial treatment was taken for
granted. The mention of learning opportunities for themselves and
their partners implies that the clients had been exposed to the idea
that such an outcome was possible in a service-delivery outlet.
These differences in the yardsticks used to measure the same en
tity, which lead to different results, as well as differing perceptions
of what constitutes "quality" among individuals, raise questions about
how researchers and policymakers should interpret the information
about users' perspectives on quality and how program managers
should apply such information. Moreover, relying upon the perspec
tive of service users overlooks the perceptions of those who stay away.
We need also to know about nonusers' perspectives, especially if we
are interested in improving the accessibility and use of family plan
ning services. Clearly, users' and nonusers' assessments of quality
should be considered in conjunction with an objective assessment of
such aspects as adherence to minimal standards of infection control,
adoption of appropriate therapeutic procedures, and the technical
competence of counselors and medical personnel. Furthermore, us
ers' and nonusers' assessments are useful only if viewed within con
text: We need to know who the clients were and where they came
from, what the facility was like, and who the service providers were,
so that we can better understand and interpret what clients say.
As for using information obtained from quality assessments to
effect changes in service delivery, one frustration for service provid
ers may be that some elements requiring change are beyond their con
trol. For example, they cannot reduce a clinic's distance from the near
est bus stop or improve roads, and they may not be able to prevent
the erratic delivery of supplies or the absence of personnel due to
hiidp-pt mfq nnr ran fhpv rnnfrnl Hap hiah rndt r»f cunralioc
T. K. Sundari Ravindran
I
73
Despite these limitations, asking clients open-ended questions
about their experiences with a service facility is still a valuable exer
cise. It often throws open a new range of concerns that do not form
L
part of our framework because of who we are and what we take for
granted. Clients' accounts of their experiences when seeking contra
ceptive services sensitize us to the realities of their lives and enable
us to examine programmatic issues with a better understanding of
their circumstances and difficulties.
■■ k’ I’- This chapter describes the experiences of rural, poor women with
the maternal and child health (MCH) and family planning services
provided by the public health system in four districts in Tamil Nadu.
The following sections profile the demographic features and MCH
r. ■
and family planning services in Tamil Nadu, describe the sources and
limitations of the data, present the women's experiences as reported
by them, discuss the findings, and present an agenda for change based
in part on the women's perceptions.
■
r
B- -
fc-
The Study Area
|,
■
-
fe:
fe"
The state of Tamil Nadu has been in the limelight in recent years be
cause of its impressive decline in fertility. Today it has a near-replace
ment level of fertility, with a total fertility rate of 2.2 children per
woman as of 1991 (RGI1991). The state's birth rate fell from 27.9 births
per 1,000 population in 1981 to 20.8 per 1,000 in 1991 (RGI 1994). The
contraceptive prevalence rate in Tamil Nadu was 57.3 percent of re
productive-age couples in 1991, ranking third highest in the country,
after the Punjab (75.8 percent) and Gujarat (57.8 percent) (GO1,
MOHFW, Department of Family Welfare 1992).
What makes Tamil Nadu's fertility decline unusual is that its in
fant mortality rate is still relatively high, at 68 infant deaths per 1,000
live births. In Kerala, which has the lowest total fertility rate in India
(2.0 births per woman), the infant mortality rate is far lower, only 21
per 1,000 live births. Tamil Nadu also has a high proportion of its
population, 32.8 percent, living below the poverty line, ranking fifth
among the 17 major states in 1987—88. In 1991 its per capita income at
current prices was Rs4,428, below the income levels of eight other
states and just above those of Kerala, Orissa, Bihar, Madhya Pradesh,
Rajasthan, and Uttar Pradesh (GOI, MOHFW, Department of Family
Welfare 1992). Tamil Nadu has a femalp lifpmrv rate nf ^9 9
/4
T. K. Sundari Ravindran
Rural Women's Experiences in Tamil Nadu
the second highest in the country but far below that of Kerala, with
86.9 percent (Rd 1992). Thus, except for its female literacy rate, Tamil
Nadu's development indicators are nowhere among the best in the
country.
For these reasons, it has often been argued that Tamil Nadu's
fertility decline is due to the effectiveness of its Family Welfare
Programme (Antony 1992; Bose 1994; Sen 1995). Tamil Nadu has a
reasonably good network of primary health centers (PHCs) and
subcenters, which cater to the rural population. In 1994 the state
ranked fifth in population size served per subcenter (4,236 persons)
and also in population size served per PHC (25,614). Each subcenter
and PHC serves an area within a radial distance of 2.13 kilometers
and 5.25 kilometers, respectively (GOI, MOHFW, Rural Health Divi
sion 1994). Overall, the health and family welfare services in Tamil
Nadu are better distributed than in most other major states of India.
A recent study of the factors underlying Tamil Nadu's fertility
decline cites the efficient management of family welfare services as
the main factor (Padmanabah 1995). According to the study, a con
certed effort was made in the 1980s to fill all field-level posts in the
Family Welfare Programme, and staff strength has been maintained
since then. Moreover, senior officers, including the chief secretary of
the state administration, have taken an actively interventionist inter
est in the program for several decades. The interest of senior officials
evoked a response from the functional hierarchies, resulting in a tradition of supervision and monitoring.
In 1991 Tamil Nadu had a ratio of one doctor per 1,230 persons,
ranking third after Kerala (1:760) and Karnataka (1:1,020). The state's
per capita expenditure on health of Rs86.10 per annum is exceeded
only by that in Punjab (Rsl06.28) and Kerala (Rs95.79) (CMIE 1994).
The program s performance in antenatal care is also exemplary.
Ninety-two percent of rural mothers and 97 percent of urban moth
ers are immunized against tetanus during pregnancy. More than 80
percent of all pregnant women receive iron and folic acid tablets; and
in 1992-93,60 percent or more had an antenatal checkup by a doctor.
Forty-nine percent of the deliveries in rural areas and 90 percent in
urban areas take place in a health facility (UPS 1995).
These--data
high levels
of coverage
coverage and
and access to
- indicate very
vciy iiign
levels or
family planning and MCH services provided by the public-sector pro-
r
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75
gram in Tamil Nadu. The central question addressed in this chapter is
whether Tamil Nadu's considerable achievements in the areas of MCH
and family planning are, in fact, indicative of high standards of care
within the public-sector program.
Sources of Data and Methodology
The assessment of family welfare services presented in this chapter
draws upon information from three sources of data, none of which
had the explicit purpose of examining client perspectives on the qual
ity of care in such services. The first source is a 1992 study of barriers
to access to family planning services among rural, poor women in
Chengalpattu and Thanjavur, Tamil Nadu, which I conducted for the
Centre for Development Studies, Trivandrum. The second source con
sists of findings from three workshops conducted by the Rural
Women's Social Education Centre in districts of Tamil Nadu in late
1994 to identify major reproductive health concerns of women and
make recommendations on how to respond to them. The workshops
also produced a list of demands for changes in MCH and family plan
ning services offered by PHCs and subcenters and district hospitals.
The methods used to gather information for these two sources in
cluded in-depth interviews, sharing of personal experiences in a
group, reports from group discussions within the workshops, and
role-plays depicting real-life incidents. The third source is an infor
mal survey of 16 health facilities catering to rural areas, which was
conducted in 1994 by three grassroots organizations in Tamil Nadu:
the Rural Women's Social Education Centre, World Vision, and
Women's Resource Centre. The purpose of the survey was to observe
the range of reproductive health services being provided, especially
at the PHC level. Information was collected by community workers
from the organizations carrying out research, and workers used a
checklist for observation. Data collection was carried out when the
workers accompanied women from their community to the local
health centers, as they often did. Of the 16 health facilities they ob
served, two each were in Madurai and Tiruchy Districts, one was in
South Arcot, and the remaining 11 were in various talukas (subdis
tricts) of Chengalpattu District. The health facilities consisted of one
district hospital (a teaching hospital), five PHCs, and 10 subcenters.
. 1
/0
Rural Women's Experiences in Tamil Nadu
A brief description of the background of the women whose views
are expressed here is in order. Practically all the women belong to
the dalit caste groups, who rank lowest in the Indian caste hierarchy
and have been for the most part economically and socially marginalized.
Most are agricultural wage laborers who own little or no land, but those
from Thanjavur belong to the fishing community and do not work out
side their homes. All the women are illiterate or semiliterate. Various
age groups are represented. In short, all are poor women from re
source-poor settings. However, given Tamil Nadu's good network
of roads and public transport, and the fact that health facilities are
functioning there, they have greater physical access to the services
than do women in many other Indian states. In addition, the women
enjoy a reasonable degree of freedom to move about and are able to
travel to nearby towns without a male escort. They are also exposed
to the mass media through television and radio programs and mov
ies made available to the public by their panchayats (village councils).
In the following sections I attempt to piece together various ex
periences and perceptions showing how the poor quality of services
compounds difficulties faced by women in controlling their fertility.
For this reason, the picture I present is more pessimistic than one that
would result from surveying a representative sample of users and
potential users. In a sense, it is an inventory of all the problems that
poor women face in seeking to access family planning services and
hence represents only one side of the story. Despite these limitations,
it is among the very few studies focusing on the quality of MCH and
family planning services in Tamil Nadu, particularly from the per
spectives of women affected.
Women's Experiences with the
Family Welfare Programme's Services
To give some coherence to the information drawn from <*'
disparate
sources on women's perceptions, I have used here the extended quality-of-care framework developed by the Pan-American Health Organ
ization and Family Health International within a broader context of
reproductive health care (Finger and Hardee 1993). I have also used
the quality-of-care framework developed by Judith Bruce (1990). The
following program elements are used to assess the quality of care re
ceived by clients in this framework:
T. K. Sundari Ravindran
• accessibility and availability of services;
• availability of basic facilities and essential supplies (because
this affects client choice);
• choice of methods;
• information to users;
• technical competence;
• client-provider interaction;
• continuity of services; and
• appropriate constellation of services, including treatment for
sexually transmitted diseases and MCH care.
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Although health facilities are physically accessible in most instances,
problems arise from inconvenient hours of operation and nonavailabilof personnel. For instance, the outpatient department of district hospitals is open only between 7:00 and 9:00 in the morning, when women
would have their hands full performing household chores. The PHCs
are open all morning long. According to one informant, however,
We have to wait in a long queue. Not everyone is given an OP [out[out
patient] slip, and if we plead, saying we have come a long way, they
chase us off like we were dogs. If you are dressed decently, you get
a different treatment. They should not treat people so unequally.
Of the 16 health facilities visited, only eight remained open dur
ing the specified hours (all morning); the hours of the rest were unpre
dictable. As for the presence of medical personnel, in only three of those
eight were doctors available throughout the clinic period. Doctors were
usually available for clinic patients two or three hours in the morning,
whereas they devoted afternoons to private practice. Women doctors,
who were especially in demand, drew patients to their private prac
tices from surrounding areas that did not have a female doctor posted
in the local PHC. Five facilities had no female physicians in attendance.
Availability of Basic Facilities and
Essential Supplies
Health centers lack basic facilities such as a water supply, toilets, and
electricity. Three of the subcenters surveyed had no electricity. The
/ <3
T. K. Sundari Ravindran
Rural Women's Experiences in Tamil Nadu
situation was worse with respect to toilet facilities and water. Only
five had toilets, and at one the toilet was filthy to the point of being
running water. Nine had access to drinking water either from a pub
lic hand pump or a public well, but there was an acute shortage in
five of these. In the remaining seven facilities, water had to be fetched
from long distances. Some women brought 18-liter cans of water with
them when admitted to the hospital because of the water scarcity.
The shortage of furniture, such as beds for deliveries and steril
ization procedures, is another problem. None of the 16 facilities had
adequate space or benches for patients to wait in the outpatient section.
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issued prescriptions and had to buy drugs from the pharmacy.
Women undergoing sterilization had to pay for blood and saline
transfusions, and even for cotton and gauze in some cases, a situa
tion they found unacceptable. Even fresh sanitary towels were in short
supply, and some women going for delivery used the home delivery
kits supplied by the auxiliary nurse-midwives (ANMs) for their
institutional deliveries.
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Choice of Methods
As is well known, the choice of contraceptive methods is limited al
most exclusively to female sterilization and intrauterine devices
(IUDs). Contrary to popular belief, some women wanted male meth
ods and complained that those methods were not available.
Why can't government insist on male methods? Always women have
to take the burden for family planning as well. The nurse, balwadi
[preschool] teacher, EDO [block development officer], everyone
comes and pesters only women.
3
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After the operation, they made me lie down. It was filthy; not even
a mat was provided. I had to spread my own sari. I lay there for a
week like this.
The health centers also had an acute shortage of drugs and es
sential supplies. Although all 16 dispensed drugs, these were only
for the most common complaints, such as colds and coughs, fever,
diarrhea, and aches and pains. For all other complaints, patients were
Pressure to accept a particular method, the epitome of lack of choice,
was common. This was especially true in the case of IUD insertions.
K
unusable. Even facilities that conducted medical terminations of preg
nancy and deliveries were found to be without toilets, the women
having to use the backyard or alleyways. None of the facilities had
79
Padma had a cesarian section for her second delivery. After re
turning home, she continued to have a slight but persistent uneasiness and pain in the lower abdomen. When her menstrual periods
resumed, the bleeding was heavy and the pain intensified. She went
back to the hospital and was told nothing was wrong. She was given
some tablets and sent home again. Her menstrual cramps became un
bearable, and she discovered something that looked like a wire protruding from her vagina. It was from an IUD, which had been in-
serted without her knowledge or consent.
Vijayalakshmi, who had pain and heavy menstrual bleeding fol
lowing the insertion of an IUD without her knowledge after her first
delivery, went to a private doctor, who charged Rs50 to remove it.
After some days, I had unbearable pain; the whole genital area felt
sore. One day my cousin took me to Madras for a checkup by a
doctor she knew well. The doctor said that the T part of the IUD
was stuck in the cervical canal, and advised me to get admitted in
hospital to have it surgically removed. I was terrified and didn't
seek help immediately. Only after three months, and considerable
coaxing by my husband, did I dare to go. I did not feel I could
trust anyone.
I
In another instance, a woman admitted for a complicated deliv
ery was sterilized without her knowledge.
I have three sons. For the third delivery, labor pains were prolonged,
and the dai [birth attendant) advised hospital delivery. I had a
c-section. They did not tell me or my mother-in-law, who came along,
that they were performing a tubcctomy. On the seventh day, when I
was returning home, they gave me 130 rupees. When asked why,
they said it was for the tubectomy. My husband and 1 returned home
with a heavy heart. We were really keen on having a daughter. What
is to be done now?
Even more common than the instances described above is the de
nial of abortion to women unless they agree to undergo a tubectomy.
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I have three daughters, and after a long gap became pregnant for
the fourth time. My daughter's wedding had been fixed, and I was
desperate to have my pregnancy terminated. I could not afford to
have a sterilization done simultaneously, since I was going to be very
busy and would have no rest. The PI IC refused me an M I P (medi:
T. K. Sundari Ravindran
Rural Women's Experiences in Tamil Nadu
80
cal termination of pregnancy] without sterilization. I went to a tra
ditional abortionist because a private doctor was unaffordable, what
with all the expenses to come. I became sick after that and went back
to the PHC. The doctor said that my uterus was perforated. But he
refused treatment, and told me to go back to where I had had the
abortion. No amount of pleading by me and my husband helped.
He said they did not have the facilities to deal with such cases.
Information to Users
The women reported that their main sources of information were the
village health nurse (VHN), the balwadi teacher, the mukhya sevika
(women's development program organizer), and the block develop
ment officer. The only methods mentioned by these personnel were fe
male sterilization and IUDs, although the women also knew of Mala-D
(an oral contraceptive brand) and Nirodh (a condom brand) from tele
vision advertisements. The information that health personnel impart
to their clients about a specific method appears to be limited to rec
ommending that method. For example, a VHN or health visitor will
ask a woman, "Can you or your relatives give me a case?"—a "case"
being a potential sterilization client. Or she will urge her client to
"have the operation; it will cause you no problems." Women who
are unable to be surgically sterilized for health reasons are not given
information about other methods.
Chinnammal has given birth to eight daughters and two sons.
Of these, six daughters and one son remain alive. She has been preg
nant three times since her tenth birth. All three pregnancies were ter
minated by a traditional abortionist, using a stick from the erukkam
tree. Because she is in very poor health, no one will employ her. Con
sequently, she seldom has more than one meal a day, consisting of
leftover rice soaked in water, which is often provided by others. She
sought "the operation" (sterilization) twice, but the doctor sent her
home each time, saying she was too weak for surgery. She wonders
how many more pregnancies and abortions are in store for her.
Lalita, who suffers from epilepsy, is also concerned about avoiding
further pregnancies. Nevertheless, she has been denied sterilization.
Particularly disconcerting is the following case, in which the
VHN failed to inform the client about the correct use of the pill.
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81
me. My husband is in Bangalore. He comes home once in two or
three months; I use the pill whenever he comes, and stop it after
wards.
According to another woman.
I take five tablets, one every day, and wait for my periods. If the
periods come, no need of taking the pill after that.
In none of the 16 health facilities studied was a specific day, per
son, or place assigned for family planning counseling and informa
tion-giving. There was no place to go if a woman or man wanted to
get information about contraception but not necessarily become an
immediate contraceptive acceptor. Women who came to these facili
ties were already "motivated" to accept sterilization, or in rare in
stances, the IUD. At the subcenters the ANM usually selected the con
traceptive method, convincing her clients to become acceptors.
Many women also mentioned the lack of information provided
on how to use the medicine dispensed to them. According to some, if
the mother and child are both given medicine, the pharmacist does
not explain which is for whom, but just puts them all together. When
the women ask for clarification, they are told, "Go ask someone who
has nothing to do. This is not my job."
Technical Competence
Several instances reported by women indicate a lack of adequate tech
nical competence on the part of health personnel. For example, more
than one woman talked of feeling pain during the sterilization proce
dure, probably because she had not received enough anesthetic.
■
When they wheeled me into the operation theatre, I saw the many
instruments, and felt scared. They gave me an injection in my back,
and my lower limbs became numb. I lay with my eyes closed, but
was aware of what was going on around me. Even while the opera
tion was going on, 1 kept feeling the pain. I literally screamed through
the whole process. What a nightmare it was! Even now I cannot bear
to think about it.
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Complaints of postoperative complications were common.
■
It is three years since the second baby was born that I have been
using the pill. I asked the nursamma [VHN] for it. She gave it to
■
When removing the stitches, the nurse just pulled at the sutures.
There was bleeding; they did not even have cotton to wipe it. After
82
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Rural Women's Experiences in Tamil Nadu
ly. ■
some days, I started getting a pricking pain in the surgical wound. I
consulted the ANM, and she said it was nothing; this is how it would
be for three months. I then went to the PHC. They gave me two tablets
and sent me back. The pain became unbearable, and pus started ooz
ing out I pressed the wound to remove the pus, and something came
out, which looked like small staple pins. I got treated by a private clinic.
I had a swelling in the surgical wound following a sterilization op
eration, and the whole area became hard. I went back to the PHC,
and they gave me some tablets. I did not get any better. When I went
to a private clinic, they said that there were air bubbles and I needed
surgery again. I am afraid to undergo surgery again. I can't afford it
either. Do you think the private doctor was telling the truth? Or could
it be another moneymaking gimmick?
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The money given to women as "compensation" for accepting
sterilization is barely adequate even to meet the transportation cost,
let alone the demands of the hospital staff.
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I didn't know it was a "current" operation [laparoscopic steriliza
tion] till after it was done. After one year my periods stopped, but I
didn't realize I was pregnant. I could meet the ANM only in the third
month of pregnancy. She took good care of me, and I had a hospital
delivery and tubectomy. How many times do they want to cut open
our stomachs?
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First they took 5 rupees for the enema. When the baby girl was born,
they took 40 rupees [50 rupees if it was a boy]. 1 paid 20 rupees for
those bringing me to the recovery area on the stretcher after the op
eration. If I hadn't, they would have made me walk back. Five ru
pees to the sweeper to bring the bed pan, 5 rupees for the hot water
to bathe the baby. I had to pay for changing the bandage every day
and buy medicines from the pharmacy. Add to this the food expenses
for my mother, who was staying with me. What would I have left
from thv 160 rupees they gave me? I would not even have money to
go home, unless I spent out of my own pocket.
In one instance following a complicated delivery of a stillborn
baby, the nurse demanded 15 rupees for cutting the umbilical cord.
Although most of these incidents involved demands for money,
there were other instances of unwarranted cruelty.
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Some of the more shocking experiences described by women relate
to the treatment they received at the hands of support staff and even
nurses at the health facilities. Corruption, in particular the demand
for money, lay behind most of these incidents.
When my stitches were removed [following a tubectomy], the nurse
asked for money. I said I didn't have any. Soon after this, she hit me
hard on my thighs, saying I was not lying down properly. I was al
ready in so much pain. After I came home, there was pus formation
on the surgical wound, but I did not feel like going back there. 1
went to a private doctor and had to spend up to 500 rupees.
I took my daughter for delivery to the district hospital. The delivery
was normal; she bore a boy. The ayah [attendant] who gave me the
good news asked for 50 rupees. But 1 had no money with me, so I
said I'd give it when my son came. They abused me and called me a
miserly peasant woman. I was very agitated, so I went immediately
to the pawn shop round the corner from the hospital, pawned my
nose ring, and paid them.
lift-- ■
There was a general perception that laparoscopy was associated
with high failure rates. Among the group of women we met, four
had experienced a sterilization failure.
A number of women reported having white discharge and pain
during urination after a medical termination of pregnancy. These may
be symptoms of reproductive tract infections (RTIs) caused by health
care providers' failure to observe adequate standards of hygiene.
T. K. Sundari Ravindran
When I said my three-day-old baby had not cried at all, the nurse
said, "Give him a whack with a cane; then he will scream and cry to
your heart's content." It was my first delivery. I was in labor for
more than a day. The nurse shouted at me, "Did you scream like
this when you lay in bed beside your husband and got yourself preg
nant?" I started to cry and said I wanted to go home even if I were
to die there. The nurse got so angry that she came back and slapped
me on my face and told me to shut up.
Such complaints were not voiced about doctors. However, our informants reported that doctors did not listen to the women's complaints,
H had no time for the women, and treated them as if they were ignorant
;
and incapable of making decisions. The doctors did not explain what
^4-was wrong or what treatment was being proposed, nor did they answer
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questions or reassure the patients or their family members. With few
fe___ exceptions, they were aloof and distant, unconcerned, and disinterested.
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84
Rural Women's Experiences in Tamil Nadu
Continuity of Services
The lack of follow-up care provided to women who adopt a method
of contraception is a well-known problem. Whatever the reasons for
this on the part of the ANM, women see this as a letdown at a time
when they are most in need of support. For those women who have
to overcome considerable opposition at home in order to undergo
sterilization, the ANM's frequent visits until she "gets the case" and
her disappearance from the scene immediately afterward are like a
slap in the face. Her failure to provide follow-up care means that
women have to seek help from private practitioners and incur con
siderable expense.
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Appropriate Constellation of Services
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To a poor, rural woman, having access to a health subcenter and a
health functionary, such as the VHN, who is unable to meet her com
mon health needs seems pointless.
J-. - ■
She [the VHN] has no medicines for headache, cannot treat children
with severe diarrhea, is not able to attend to emergencies like poi
soning.
That the VHN is not even available to conduct deliveries causes
considerable discontent.
The nursamma is never there to conduct delivery. The dai has to be
called, and has to be paid 50 rupees and 2 tnarakkals [a local measure
equivalent to about 15 kilograms] of paddy. Do they [the govern
ment health services] expect us to deliver only between 10:00 and
5:00? What a waste of a salary!
A common complaint is that women with symptoms of an RTI,
including those who develop the symptoms after a surgical proce
dure or an IUD insertion, do not receive help at the subcenter or even
at the PHC. Often they must to go to a private practitioner, or to the
private clinic of the PHC doctor. The study of the 16 health facilities
confirms this perception. Services for most gynecological problems
were available in only one district hospital. In all other health facili
ties, not even a pelvic examination was done on women with gyne
cological complaints. Staff there either treated only the women's
symptoms or referred the women to the district hospital.
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T. K. Sundari Ravindran
85
Evidence from Other Studies
How representative are the experiences described above? Do not the
increasing acceptance of contraception in Tamil Nadu, and the state's
success in controlling population growth, imply that the quality of
services is good? Only a few published studies have examined the
quality of care in MCH and family planning services in Tamil Nadu.
Reports of the Surveillance System for Sterilization Project, funded
by the United Nations Population Fund (UNFPA), suggest that all is
not well with the Tamil Nadu program.
One of these reports, on the quality of care in 51 facilities per
forming sterilizations in Tiruchy District between 1990-91 and 199293, noted the high rate of mortality following tubectomies—4.3 per
10,000 procedures, as compared with 1.0 per 10,000 reported from
other parts of India (GIRHFW 1994). Another report found that mor
tality rates following tubectomies in North Arcot (Ambedkar) Dis
trict for the period 1989-90 to 1993-94 were similar, at 4.4 per 10,000
(Abraham and Joseph 1994). Both studies observe that most of the
deaths could have been prevented had there been adequate screen
ing, adherence to asepsis, and appropriate postoperative care.
For example, 48 percent of sterilization deaths in North Arcot
were due to infections, mainly septicemia and meningitis. Most of
these clients had delivered at home and reported later to the hospital
for sterilization. The screening of patients prior to surgery was cur
sory, and because of this the presence of puerperal infection may very
likely have been missed. Some 19 percent of the deaths were associ
ated with severe anemia. Although the Indian government's standards
recommend the exclusion of women whose hemoglobin levels fall
below eight g/dL, staff at some of the hospitals in the district were
unaware of this standard and had used seven g/dL as the lower limit.
Complications of anesthesia were reported to be the cause of death
in six cases (Abraham and Joseph 1994).
Failure rates for laparoscopic sterilizations were as high as 29.6
per 1,000 in Tiruchy District (GIRHFW 1994). Women's perception
that this is not a reliable procedure therefore has some basis.
The reports' descriptions of the way clients were treated read
very much like the women's accounts described in the previous sec
tion. In Tiruchy, for example, the operation theater complex in nine
out of the 11 government hospitals and in all eight main PHCs lacked
86
Rural Women's Experiences in Tamil Nadu
adequate facilities, including such basics as running water and sup
plies for emergency cases. In four of the eight main PHCs and four
government hospitals, there was no running water and the water
carriage system was not functioning. This meant that clients could
not bathe on the day of their surgery. Women undergoing steriliza
tion in the laparoscopic camps conducted once a week in the nine
government hospitals had to face many unpleasant experiences. Most
had to go without food or water for about 16 hours, from the morn
ing of the surgery until that evening. The facilities were overcrowded,
and there was not enough fresh linen. The doctors performing surgery
could not even wash their hands between procedures, and the instru
ments could not be sterilized properly (GIRHFW 1994). In North Arcot,
preoperative examination of mothers in eight of 14 hospitals consisted
of merely looking for pallor, unless a woman voluntarily gave a his
tory. The hospitals used antibiotics liberally, both pre- and postoperatively, even when there was no indication of need. Surgical technique
varied from center to center. Patient counseling and advice at the time
of discharge were totally neglected (Abraham and Joseph 1994).
In Tiruchy a small sample of clients was folio wed-up within six
months after surgery as part of the monitoring and surveillance program.
Postoperative complications were reported for 15 percent of tubectomy
clients and 32 percent of laparoscopy clients. A quarter of the tubectomy
clients had developed wound infections, and 13 percent had white dis
charge. The corresponding figures for those who had undergone
laparoscopic sterilizations were 3 percent and 15 percent, respectively.
Thirty-three percent of tubectomy clients and 22 percent of laparoscopic
sterilization clients complained of abdominal pain, which in some cases
could have been associated with pelvic inflammatory disease; this pos
sibility was not investigated further, however. Most of the women who
had sought treatment from government facilities for postoperative prob
lems (84 percent) said that they were not satisfied with the services re
ceived. Tire surveillance team observed that the VHN did not visit women
in their homes in the immediate postoperative period (GIRHFW 1994).
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Discussion and Recommendations
All these findings indicate that Tamil Nadu has a long way to go be
fore high-quality family planning services are available as part of a
Msiz-
T. K. Sundari Ravindran
comprehensive client-centered reproductive health care package. Lack
of facilities and resources, the pressures of a target-driven approach
to family planning, and a pervasive class and status consciousness
have created a culture of apathy and high-handedness that is very
disconcerting. The corruption and lack of accountability on the part
of service providers described by the women we interviewed, even if
we were to assume that such incidents are not widespread, reveal a
deep malaise in the system. The private sector benefits from the weak
nesses in the public system. Private practice by practitioners who also
work in the public sector helps those who can afford to pay for better
services, even in the government facilities, while the poor lose out.
Unfortunately, Tamil Nadu's success in achieving lower fertil
ity has detracted attention from the limitations of its MCH and fam
ily planning services. Some may argue that the high levels of family
planning acceptance in the state are sufficient evidence of good serv
ice quality. The following statement by one of the women interviewed
reveals that there are other reasons women seek family planning ser
vices:
We do not have enough to make ends meet, not even a decent hut
to sit in or a pair of oxen to work with. With a drunkard husband,
low wages, and high prices, we can't give our children two decent
meals a day and bring them up. Out of such dejection, we women
come forward for family planning.
In the workshops conducted in the three study districts, women
clients proposed a number of suggestions for improvement and
change. These suggestions are by no means exhaustive, but they do
reflect what the women felt to be most important. The proposals fall
into four broad areas: (1) basic facilities; (2) comprehensive services
provided with sensitivity and civility; (3) family planning services;
and (4) other reproductive health services.
Basic Facilities
• PHCs and hospitals should have electricity, drinking water,
clean toilets, and water.
• Beds should be available for all surgery and delivery cases.
• Proper facilities should be available for surgery; for example,
.surgical tables should replace ordinary benches, and properly
Rural Women's Experiences in Tamil Nadu
88
equipped surgical units should replace makeshift operation
theaters.
• Hospitals should be made convenient and helpful to patients
and clients. There should be greater sensitivity to the difficul
ties faced by illiterate users. At present the consulting room,
pharmacy, injection room, and dressing room are located in
different places, and there are no clear instructions for find
ing them, especially for clients who are illiterate. At times cli
ents have to return home without using a service because they
cannot find the room in which it is located or anyone sympa
thetic enough to help them.
• There should be an adequate supply of essentials, such as cot
ton, gauze, sanitary towels, and clean sheets.
• Each PHC should have an ambulance. It should also have a
telephone so that clients can contact it and so that the PHC
can contact other referral facilities.
Comprehensive Services Provided with
Sensitivity and Civility
• The outpatient department should be open at least all morn
ing long.
• Doctors should be available during the specified outpatient
hours.
• Outpatient slips should be given to everyone who has come
for medical help, and no one should be turned away without
being given attention.
• Poor and lower-caste patients and clients should be treated
courteously and should not be abused.
• Doctors should be well trained, provide appropriate treatment,
and clearly explain to patients and clients what their symp
toms indicate and what the PHC is doing to help them.
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Family Planning Services
• The advantages and disadvantages of all available methods
should be explained to clients, who should then be given the
option of choosi ng—or not choosing—from among them.
T. K. Sundari Ravindran
Other Reproductive Health Services
• The VHN should always be available at the subcenter for de
livery cases. She should not be frequently transferred. The lo
cal dai should be trained, appointed as her assistant, and paid
by the government.
0
Subcenters should be more than service points for MCH and
family planning services; they should provide first-level help
for any health problem.
• There should be proper guidance, treatment, and referral for
gynecologic problems.
In addition, the workshop participants called for an end to corruption and greater' accountability and responsible behavior on the
part of health service providers. Specifically, they recommended the
following changes:
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• Male family planning doctors and workers should promote
male methods of contraception.
• Women who choose sterilization should be told whether they
are having laparoscopy or tubectomy.
• No procedure should be carried out without the client's knowl
edge and consent.
• Every effort should be made to minimize the risk of steriliza
tion failure.
• Service providers should not delay or deny medical termina
tions of pregnancy.
• Complications such as pus formation after sterilization should
be taken seriously. PHC staff should give women proper in
structions on how to take care of themselves after surgery in
stead of telling them, when they return with a complaint, that
it is their fault.
a breach or difficult delivery, should take responsibility for
ensuring that the woman is admitted to the referral center.
• The PHC should also not let the woman down. If faced with a
complicated delivery that they are unable to deal with, PHC
staff should arrange to transport the woman to a referral facil
ity, accompanied by someone who can supply her case history.
90
Rural Women's Experiences n Tamil Nadu
• Problems following a woman's adoption of a contraceptive
method should be attended to by the VHN and the PHC or
hospital where the service was provided.
To bring about the changes demanded by the women requires
not so much money as something far more difficult: a fundamental
change in values and attitudes; a move toward more caring, people
centered, sensitive, and responsible service delivery. A good begin
ning has been made with the recent discontinuation of family plan
ning targets. The new reproductive and child health approach that is
on its way to implementation in Tamil Nadu brings the promise of
precisely such a change. There is no doubt that the managerial and
administrative skills of the program personnel, which have made
Tamil Nadu's family planning program among the most effective in
the country, could now serve to transform it into one with a high qual
ity of care as well.
References
Abraham, Sulochana, and Abraham Joseph. 1994. "Monitoring and surveillance
system of surgical sterilization," unpublished document, Christian Medi
cal College, Vellore, Tamil Nadu.
Antony, T.V. 1992. "The family planning programme: Lessons fro n Tamil Nadu's
experience," The Indian Journal of Social Science 5(3): 319-330.
Bose, Ashish. 1994. "TN's successful demographic transition," Financial Express
(Madras), 4 January.
Bruce, Judith. 1990. "Fundamental elements of the quality of care: A simple
framework," Studies in Family Planning 21(2): 61-91.
Centre for Monitoring Indian Economy (CMIE). 1994. Basic Statistics Relating to
States of India, September 1994. Bombay (Mumbai): CMIE.
Finger, W.R. and K. Hardee. 1993. "What is 'quality of care'?" Network 14(1): 4.
Gandhigram Institute of Rural Health and Family Welfare (GIRHFW). 1994. Sur
veillance System for Sterilization in Tiruchirappalli, Tamil Nadu. Ambathurai,
Dindigul, Tamil Nadu: GIRHFW.
Government of India (GOI), Ministry of Health and Family Welfare (MOHFW), De
partment of Family Welfare. 1992. Yearbook, 1990-91. New Delhi: MOHFW.
Government of India (GOI), Ministry of Health and Family Welfare (MOHFW), Di
rectorate General of Health Services, Rural Health Division. 1994. Rural Health
Statistics in India for the Quarter Ending September 1994. New Delhi: MOHFW.
International Institute for Population Sciences (UPS). 1995. National Family Health
Survey (MCH and Family Planning): India, 1992-93. Bombay (Mumbai): UPS.
McGinn, T. 1993. Draft quality of care protocol for use during supervision visits.
Presentation at the Evaluation Project Service Delivery Working Group Meet
ing, 9-10 December 1992, as quoted in Quality of Care in Family Planning: A
Catalog ofAssessment and Improvement Tools, eds. Karen Katz, Karen Hardee, and
MicheleT. Villinski. Durham, N.C.: Family Health International, pp. 143-150.
I'
!
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I
VI
r
h
t
I'
. I'
I
i
I
Sv
W,..-
I; i
(■
S'
I ■
L
I SsaK&a
■■
■! fe'
i. ix. ouiiuari i\avinuran
Padmanabah, P. 1995. "Causes of fertility decline in Tamil Nadu: An explor
atory study," unpublished
published manuscript. Population Foundation of India,
New Delhi.
Registrar General, India (RGI). 1991. Sample Registration System: Fertility and Mor
tality Indicators. New Delhi: Government of India.
-------- . 1992. Final Population Totals: Brief Analysis of Primary Census Abstract, se
ries I, paper 2 of 1992. Census of India 1991. New Delhi: Government of India.
-------- . 1994. Sample Registration Bulletin, vol. 28, no. 2. New Delhi: Government
of India.
Sen, A. 1995. Population Policy: Authoritarianism versus Cooperation. The John D.
and
ancl Catherine T. MacArthur Foundation Lecture Series on Population Is
sues, New Delhi,
Delhi. 17 August.
Aueust.
sues.
Vera, Hernan. 1993. "The client's view of high-quality care in Santiago, Chile,"
Studies in Family Planning 24(1): 40-49.
•
L:
I
Sandhya Barge • Lakshmi Ramachandar
In this chapter we present data from qualitative observations of
provider-client interactions that took place between October and De
cember 1994 in two primary health centers (PHCs) in the state of
Madhya Pradesh. Our study seeks to highlight some of the special
features of the interactions between primary care providers and their
clients in the Indian health care system.
v
6
Provider-Client Interactions
in Primary Health Care:
A Case Study from
Madhya Pradesh
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Objectives
The general objectives of the study are to assess provider-client in
teractions in a selected rural region of Madhya Pradesh in order to
identify possible means of improving services. More specifically, we
K address the following issues:
• How clients and providers interact in specific types of settings;
• Possible differences in the quality of interactions in diverse
clinical and community settings;
>;
• Differences in clients' access to the services being provided,
and the reasons for those differences; and
gl I
• Special features of the health care system and other factors in
fluencing the performance of service providers.
I
SANDHYA BARGE & LAKSHMI RAMACHANDAR
During the past 10 years there has been increased interest in the ef
fective provision or supply side of primary health care and family
planning services. Earlier frameworks for the adoption of family planr^ng put greatest emphasis on prospective clients' knowledge and
attitudes toward contraceptive technology—that is, on the "demand
side of family planning programs. In examining family planning pro
grams and other health services, many researchers have posited that
the effective provision of services can greatly increase contraceptive
use (Cleland et al. 1994; Khan, Patel, and Gupta 1996; Phillips et al.
1993; Simmons et al. 1988; Simmons and Elias 1994). Simmons and col
leagues (1988) in particular have shown the important and complex
roles that female health workers (FHWs) play in affecting the "sup
ply-demand interaction" in family planning and other services. They
noted that health workers reduce the fear of contraceptive technology,
counter religious barriers, and dispel other common objections to fam
ily planning. Many of the same factors apply to maternal and child
health (MCH) care and to other primary health services, which are of
ten included among the responsibilities of community health workers.
Bruce (1990) has analyzed some of the important elements in the
presentation of family planning services in her framework for evalu
ating family planning programs. Seidman and Hom (1991) provide a
useful set of discussions on the applications of field research to the de
velopment of effective programs.
93
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Methodology
The data for this study consist of observations made at the two PHCs,
followed by day-long observations of six auxiliary nurse-midwives
(ANMs) connected with the two centers. Each ANM was observed in
her activities for six consecutive days. These observations included
two days in the PHC and four days in the village area, where the
ANMs had meetings with clients in the subcenters as well as during
home visits. Our team witnessed interactions with 55 clients at the
PHCs (Table 6.1) and with 210 clients in the villages.
The interactions in the two PHCs were observed by separate re
search groups, each consisting of three trained observers. When the
researchers moved to observing the ANMs at the subcenters, the two
teams were recombined into pairs. One member of the team went
with the ANM to observe her interactions with clients, while the other
team member visited other households in the community. We are
aware that the presence of the observers may have affected the be-
Sancihya Barge • Lakshmi Ramachandar
Provider-Client Interactions in Madhya Pradesh
94
K
TABLE 6.1
Activities in two PHCs during four days of observation
(two days at each PHC): Vidisha District, Madhya Pradesh, 1994
Day
No. of hours
of operation
(FP/MCH clinics)
No. of clients
FP
1
2
3
4
Total
3.5
3.0
4.0
3.5
14.0
14
18
12
11
55
1
2
11
3
2
4
10
2
13
2
8
4
36
Type of clients
MCH
Curative
3
9
|
FP=family planning; MCH=maternal and child health; PHC=primary health center.
havior of the ANMs, particularly at the beginning of the observations.
The observed staff member may have been self-conscious and un
natural in her actions, possibly changing her behavior to conform
more closely to "ideal performance." However, we believe that our
continuous observation of each ANM over a period of six days greatly
reduced any potential observer effects.
Of the six ANMs we observed, only one lived in the work area.
This was because of the extremely shabby condition of most of the gov
ernment quarters allotted to these workers. The subcenters in which
they were supposed to reside and work were dilapidated and had no
water, electricity, or toilet facilities. The buildings did not have locks
or latches. Therefore the ANMs commuted by bus from the district
headquarters, 30-50 kilometers away. Their average time spent in com
muting was more than one hour in each direction. One of the ANMs
stayed at her subcenter because it was a new, well-built pukka house
(constructed of brick and cement). She had completed more than two
years of service at that location and had received awards in recognition
of her high degree of service to the communities under her jurisdiction.
All the ANMs had at least a tenth-grade education and had re
ceived the standard three-month ANM training course. They were
all upper-caste women, ranging in age from 30 to 50 years. All of them
had served as ANMs for at least five years, although not necessarily
in their current post.
Because two observers accompanied each ANM on her visits to
the villages, one member of each team was able to go about the vil
lage, engaging household members in informal conversations about
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clients' perceptions of the family planning and MCH programs, while
the other stayed to observe the ANM in her visits. The researchers
talked with a dozen or more women in each village. They were in
structed to find current family planning users, pregnant women,
laparoscopy acceptors, and MCH cases. They were also told to pay
attention to any cases of "unmet need"—that is, women who wanted
to regulate their fertility but were not currently using any contracep
tive method. The researchers held informal group discussions with
some of the village women, as well as with groups of ANMs. They
also visited villages on the periphery of the areas served by the
subcenters. The researchers did not take notes during the informal
discussions with the villagers, but they were instructed to write down
important observations immediately after the encounters.
Observations in Two PHCs
The two PHCs selected for the study are each located at crossroads
approximately 3.5 kilometers from the nearest village. One PHC is
located in a small rural bazaar with a dozen or more shops that sell
clothing, miscellaneous supplies, and foodstuffs. One of the PHC
buildings is a standard government structure with eight rooms, in
cluding a small operation theater. The doctor's residence is a threeroom brick and concrete building, situated near the PHC. The other
PHC was originally a subcenter and was later upgraded to a PHC; it
has only two rooms.
The medical officer, paramedics, multipurpose workers (MPWs),
block extension educators, lady health visitors (LHVs), and ANMs
were all present during the four days of observation (two days each
at two clinics). Also present were the technicians, drivers, and atten
dants. The clinics and the surrounding areas were quite clean when
we observed them. Individual rooms were swept and mopped with
phenyl, a disinfectant. The examination tables and chairs in the medi
cal officers' rooms were clean and free of dust. However, clients were
observed littering and creating unsanitary conditions. Some clients
spat tobacco or betel leaves on the ground near the building and scat
tered groundnut shells about the premises.
All the clients were registered in the outpatient department by
either an LHV or an MPW. After registering, the clients were re-
96
Provider-Client Interactions in Madhya PradesK-'*’
ferred either to the family planning and MCH clinic or to curative
rooms, depending on the purpose of their visit. Registration was
conducted on the open veranda of the PHC. The PHC's outpatient
department functioned from 10:30 a.m. to 1:00 p.m. The PHC func
tioned only three to four hours a day, on average. We observed that
there was no place where the clients could sit comfortably while
waiting for service. The veranda did not have any benches, stools,
or chairs. As a result, clients sat on the floor or wherever they could
find space.
The health providers were assigned specific tasks in discharg
ing their day-to-day work. The medical officer treated all the cura
tive cases. An MPW or LHV registered the clients. These personnel
replaced each other intermittently. The LHV and the ANMs conducted
the family planning and MCH clinics. In general the clinic staff car
ried out these activities systematically, without confusion or dupli
cation of effort.
The doctors performed at least a minimal medical examination
of all their clients. This included checking the client's blood pressure
(BP) and pulse rate; giving a chest examination using a stethoscope;
and examining the client's tongue, nostrils, eyelids, and skin. In con
ditions of poor visibility they used a flashlight.
One of the PHC doctors had an especially friendly and engag
ing style of interacting with clients. He asked about their crops, their
children, and other domestic matters. The other doctor was also
friendly toward the clients and had good interaction. Both seemed to
be patient and unhurried. They showed none of the abrupt unfriend
liness that is so often noted in observations of rural health centers.
The doctors spent an average of at least seven or eight minutes with
each client.
Most curative cases were referred to the medical officers in the
PHCs. Because our study focused on family planning and MCH cli
ents, there was not much opportunity to observe curative care, which
was conducted in a different room. Nonetheless, we did observe a
limited number of curative cases as well. This was possible when the
family planning and MCH clinic activities were closed but the cura
tive services were still functioning.
The department had more curative cases than family planning
and MCH cases. Medical officers were present in each PHC on all
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Sandhya Barge • Lakshmi Ramachandar
97
four days during the outpatient department's hours. It could there
fore be inferred that their presence ensured services to the clients.
Their behavior toward all the clients was polite and sympathetic, ir
respective of whether they were curative, family planning, or MCH
cases. In both PHCs, clients could gain access to medical officers dur
ing emergencies before and after the outpatient department's hours,
as the medical officers resided on the premises.
Interactions at the Family Planning and
MCH Clinics
Four clients had come to receive their oral contraceptive pills. They
were 22-25 years old and had been using pills for the past one to two
years. All four had two living children, the youngest child's age rang
ing from 6 months to 18 months. Two of the clients had come with
their husbands, the third had come with her husband and a brotherin-law, and the fourth was accompanied by a female friend. In addi
tion to these four "routine cases," the following vignettes illustrate
some of the situations and problems handled at the clinics.
Case 1: Motivating for Sterilization
When the client entered, the following conversation took place with
the ANM:
I
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ANM: How are you?
Client: I am fine.
ANM: What problem do you have now?
Client: I have finished my tablets. I am going to my relatives' house
in the next village. I thought I should take more tablets.
ANM (giving the client pills): How old is your last child?
Client: He is 1 year and 6 months now.
ANM: I think you have two children.
Client: Yes.
ANM: Why don't you stop taking these oral pills and go for an op
eration?
Client: My mother-in-law says we should have one more child.
ANM: What does your husband say?
Provider-Client Interactions in Madhya Pradesh
Sandhya Barge • Lakshmi Ramachandar
Client: He does not say anything; he only listens to his mother.
fcI'
ANM: You make up your mind. Already you have two children. We
are holding a laparoscopic camp in the PHC. The best surgeon is
coming from Bhopal. You can get operated. Make up your mind.
The client remained silent.
The client said nothing further.
1;
ANM: From your silence, can I take it that you have agreed?
i h
Client (nodding and smiling): No, I have to get permission from the
elders in the family.
S-.
ANM: Who has accompanied you?
Client: My friend.
■
ANM: Please talk to your elders and decide soon. It is only for your
good that I am giving this advice.
tfr
With this the dialogue ended.
I
Case 2: Seeking Medical
Termination of Pregnancy
8c ■
fc'
Ramkhali was 22 years old and had come to ask for medical termina
tion of her pregnancy (MTP). She was accompanied by an elderly
woman. As she entered the family planning clinic, the following ex
change took place between the LHV, the ANM, and Ramkhali (client):
ANM: What, have you become pregnant?
Client blushed and nodded her head.
ANM: When did you have your last periods?
Client: I don't remember exactly, but two months before our village
festival time I had my last periods.
ANM and the LHV (addressing the researchers out of the client's hear
ing): See, Madam, the villagers do not even remember when they
had their periods. You were asking us what problems we are facing,
[and now] you are seeing it yourself. This lady is upper-caste and
[even] she does not know. Scheduled-caste women have an even
greater difficulty in narrating important information.
LHV (to client): How old is your child ?
Client: We celebrated his first year birthday last month.
ANM: Were you not following any method?
1p
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Client: I am fine.
I
LHV: Who is this old lady? Is she your mother?
Client: No, she is my aunt. She has come from another village. She
has had severe pain in her knee for six months. So I brought her here.
The client was silent and did not lift her head. At this point the
researchers sensed that they were interfering with the sensitive coun
selor-client interaction. To allow a spontaneous and free flow of responses, they moved out of the room and stood at the doorstep be
hind a screen. They could still observe the interaction and overhear
the dialogue, but the client could not see the researchers. The client
seemed more relaxed and willing to continue the discussion.
Client: My first child is frequently falling sick, and I am also not keep
keep-
ing well. I do not know what to do now. I am not interested in this
pregnancy.
ANM (addressing the older woman): Did you register your name outside?
. Woman: No, I did not know I had to register.
ANM: Get your name registered outside on that veranda and go in
side and wait. Our doctor will come and examine you.
J
Woman (leaving and addressing the client): You discuss y<our problem.
I.
ANM (to client): What is your problem?
'>
The client remained silent, lowering her head shyly and rubbing
the floor with her toe.
ANM (observing her silence and addressing the LHV): I think she has
conceived.
ANM (to client in a friendly tone): Other clients are waiting for me.
Already it is 12:15 p.m. Now please tell me what you want.
■
Client: Yes, I will try, but nothing is in my hands.
LHV (knitting a sweater): How are you?
99
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ANM: You people always have late regrets. When we advise you,
you do not take our advice and now, when you have a problem you
come to us. What is best for you now is, you continue with preg
nancy this time and get operated after the second child, or if you
want to have one more child you can go in for a loop.
Client: I wanted to terminate my pregnancy.
ANM: We do not have termination facilities. Already you are two
months pregnant. You must go to either Basoda or Vidisha District
100
Sandhya Barge • Lakshmi Ramachandar
Provider-Client Interactions in Madhya Pradesh
ANM: Did you go back to the same hospital and consult?
Hospital. But why do you want to go for termination? You can have
this child and get operated after the second child.
The interaction ended here, and the ANM signaled for the next cli
ent to come inside. The ANM wrote a referral for MTP on a separate slip
of paper, giving it to the client to take with her to the district hospital.
The ANM and the LHV had interacted with this client for nearly
10 minutes. Most of the time the client had remained silent. Despite her
silence the health providers were courteous to her, at least as compared
with many health providers we have observed in similar situations.
Client: Yes, I have been there several times, but the sister avoids me
and keeps telling me that the doctor who operated is not there and
they cannot do anything now.
i
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ANM: Since how many months have you missed your periods?
Client: More than three months.
ANM: Once you had missed your periods, why did you delay the
matter? What were you doing all this time?
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Client: I went as soon as my period stopped. I have gone to several
places. Everybody said you go to the place where you got operated.
The hospital [staff] where I got operated are not giving any solu
tion. Meanwhile, I lost time.
a
Case 3: Tubectomy Failure
Chandnibai was an upper-caste woman, 35 years old, with four chil
dren (two boys and two girls). Seven months earlier she had under
gone a tubectomy. After the operation she had her period for three
consecutive months, but after the third month she began missing her
periods. As she entered the clinic she was received by the ANM.
ANM: We are equally helpless here. The only alternative for you is
to go to Vidisha District Hospital and get this pregnancy terminated,
and again you must undergo sterilization.
Client: I have been already operated. Why should I undergo surgery
again?
t
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ANM: I have not met you before, and by the way what is your name?
ANM: The operation has failed. That's why you have become pregnant.
’
Client: But that is not my fault.
I
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Client: Chandnibai.
ANM; Which place do you belong to?
ANM: We understand it is not your fault; it is totally the fault of the
surgeon who operated on you. Sometimes, though very rarely, it hap
pens, and it is your bad luck [that] it has happened to you. [The|
best [solution] is to allow the pregnancy and get laparoscopic steril
ization done [afterward].
I
Client: Actually our native place is Sironj. Now we are staying in
Basoda.
ANM: Are you coming all the way from Basoda?
I
Client: I will be losing my health.
' i
ANM: There is no other alternative. Would you please go now.
Client: Yes, my husband had some work on this side. He has also
come with me.
ANM; What is your problem?
101
Client: I underwent tubectomy in Basoda Government Hospital, and1
now after three months I have not had my periods.
Dissatisfied, anxious, and angry, the client walked outside to her
husband. The failure had been in the surgery conducted in Basoda
District Hospital. Even so, the ANM spent more than 10 minutes with
this client. She could only direct her to Vidisha for a medical termi
nation of her pregnancy. The ANM had reviewed her whole history
in order to understand the problem. Both the ANM and her super
vising LHV were sympathetic to this client.
I
ANM: When did you undergo operation?
IsI';.. .
Client: Seven months ago.
ANM: Who operated—was it a male or a lady doctor?
Client: Male doctor operated.
I >x
ANM; How many children do you have?
Client: Four children, two boys and two girls.
ANM: Did you get your periods after the surgery?
. x f
,7^ (
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Client: Yes, for three months I got them, and now it has stopped^ ( -C-
f.. |
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E
v.
Case 4: Laparoscopic Complication
■ Another client entered who had undergone laparoscopic sterilization
the PHC two weeks before. Now she had severe pain and swelling
surrounding the operated site. As soon as she came inside she was
kp-i^ 06654
102
Provider-Client Interactions in Madhya Pradesh
Sandhya Barge • Lakshmi Ramachandar
recognized by the ANM and LHV, who greeted her and offered her a
seat.
E■
ANM: What, do you have any problem?
Client: Yes, I have very much problem, and I have pain and it is un
bearable.
ANM (holding the client's hand): Please lie down on this bench.
The door that led outside was closed. The ANM examined the
client's wound, which was infected and bleeding.
£
: Bfc
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ANM: Don't worry, I will give you medicine and take you to the
doctor.
Client: Yes, my mother and brother.
MO: You please wait. At 3:00 p.m. I am going to Vidisha Hospital. I
have a meeting. I will take you and you will be examined there.
r
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The ANM was polite and examined the client. Upon seeing the
complication, she personally took the client to the medical officer and
also gave her antibiotics to control the infection. The medical officer
also examined the client and agreed to take her, along with the client's
mother and brother, to Vidisha District Hospital for treatment. In
stead of allowing the complication to worsen, the clinic's staff offered
an immediate solution to the client. They felt obliged to take her to
the hospital because she had undergone surgery at this PHC.
r ■
Cases 5 and 6: IUD Clients
r;
Two women came to the PHC for intrauterine device (IUD) services.
One of them came for removal of an IUD, the other to accept one.
The first client was 27 years old and had two girls. She had been
using an IUD for two and a half years. She wanted to have it removed
so that she could have a boy.
The ANM asked the researchers to go outside and closed the
door. A few minutes later, when the door was opened, she was re
moving her gloves, after which she washed her hands, using soap.
The client's privacy was thus maintained during the removal of the
IUD, and the ANM used gloves for the procedure.
The second client was 24 years old and had an 18-month-old
child. She had been urged earlier by the ANM to accept an IUD and
at last had made up her mind to do so. In this case also the research
ers were asked to leave the room during the procedure. Within five
minutes the client came out. As she was leaving.
ANM: If you have any problems, like bleeding or back pain, come
back immediately.
The ANM gave the client antibiotics and led her to the medical
officer. The medical officer (MO) examined her.
MO: Has anybody accompanied you?
103
The ANM had inserted the IUD under the supervision of the
LHV. It is difficult to interpret why the ANM had requested the pres
ence of the LHV. Perhaps the ANM had wanted to be doubly sure
that she was inserting the IUD correctly. As a general observation,
the dependency of ANMs on LHVs for oversight during such proce
dures could be eliminated if the ANMs were given more practical
training, particularly in IUD insertions.
Cases 7 and 8: Antenatal Checkups
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ANM: I am removing this now, but after the childbirth, whether you
have a boy or a girl, you must undergo sterilization.
W;- •
Two clients came for antenatal checkups. Both were accompanied by
elderly female relatives.
The ANM received the first client and offered her a seat. The
woman was in an advanced stage of pregnancy. The ANM removed
a needle and syringe from the steaming container (pressure cooker),
which was kept closed, and administered a first dose of tetanus tox
oid (TT). The ANM asked the client to lie down. As instructed, the
client lay down on the bench. The researchers wanted to leave dur
ing the examination but were asked to remain and observe.
Both antenatal clients received physical examinations, which in
cluded pressing the upper portion of their feet to check the level of edema,
examining the lower portion of their eyelids to check for anemia, noting
their weight, checking their BP, and examining the elevation of the uterus
fundus to estimate fetal growth. One client was given 100 iron and folic
acid tablets for anemia. She was nearing her third trimester of pregnancy.
104
Sandhya Barge • Lakshmi Ramachandar
Provider-Client Interactions in Madhya Pradesh
Both clients appeared to be comfortable during the physical examina
tion. Both were asked to return in a month. The clients were then given
small bottles and referred to the laboratory for urine and blood tests.
|§ .
[
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Cases 9 and 10: Postnatal Problems
Two clients were having abdominal pains in their postdelivery pe
riod. Hence they had returned to the clinic to meet with the ANM.
i ||
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ANM: Place of delivery?
Client: Home.
ANM: Who conducted?
Client: Dai [traditional birth attendant].
ANM: Did you have any complications during delivery?
Client: I had three days of labor pain.
T
£
After noting this information, the ANM asked the client to leave.
She collected more or less the same information from the other post
natal client. The ANM thus spent about eight minutes with each cli
ent but gave them no medication or advice concerning their abdomi
nal pain. She did no family planning counseling, nor did she ask about
their lactation status.
E
II
The case of Geeta, a 24-year-old upper-caste woman seeking an abortion,
illustrates the problem of maintaining privacy at the registration desk.
She approached the desk, which was then attended by the male health
worker. A number of other people were sitting and standing near the
registration desk. Consequently Geeta was unwilling to state her prob
lem at the registration desk. She was admitted to the family planning clinic,
where she was able to confide her problem to the ANM. Lack of privacy
could easily be avoided by curtaining off the registration area. This case
also indicates that FHWs should always handle intake registration.
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Five clients brought their children to the PHC for immunizations. All
the children received DPT (diphtheria, pertussis, tetanus) and OPV
(oral polio vaccine) inoculations. Sterilized needles and syringes were
used for the injections. The ANM changed the needles for each new
client. During these encounters she encouraged some of the mothers
to accept sterilization.
Four women came to the PHC for a new supply of oral contra
contra-
ceptive pills (OCPs), and all were provided with services. The ANM
encouraged two of them to undergo laparoscopic sterilization; in both
cases the last child was more than a year old and both clients already
had two sons. The ANM did not try to motivate the other two OCP
clients, who had two daughters each. She was well aware that rural
women would not accept sterilization unless they had at least one
son. The ANM spent five or six minutes trying to persuade the two
clients with sons to come to the sterilization camp, but only about
minute attempting to persuade the other two clients, who were
simply provided with a fresh supply of OCPs. The ANM was cordial
and courteous in her interactions with the clients. She offered them
seats during their sessions with her.
Observation at Subcenters
Case 11: A Problem of Privacy for MTP Clients
Other Clinical Activities
105
1
I
I
The observers spent two days observing client-provider interactions
at two subcenters. On both days the attending ANMs conducted clin
ics for only one to one-and-a-half hours. The total number of clients
was 14; 11 were curative cases and three were family planning clients.
The team reached the first subcenter at 10:00 a.m. Upon arriv
ing, they learned that the ANM was taking a bath and getting ready.
The team waited outside for nearly one-and-a-half hours. At 11:30
a.m. the ANM came outside and greeted the team. She told them that
the subcenter had only one room. As the observation team entered
the room, they saw some mattresses and cots piled up in one corner.
A few utensils were kept on the floor, and there was no table, chair,
mat, or shelves for storing the clinic's articles.
ANM (in a tone offrustration): There is no furniture or mat to treat
the visitors. There is no examination table, and how can I conduct my
clinic here? And even if I remain here for a long time, clients do not
come here, and even if they come I am unable to provide the services.
Researcher: What kind of facilities, if given, would improve your work?
ANM: First of all, I do not have a BP [blood-pressure instrument],
and this weighing scale is out of order. Without these two instru-
1U6
Sandhya Barge • Lakshmi Ramachandar
Provider-Client Interactions in Madhya Pradesh
I
rI
merits how can I treat the ANC [antenatal care] cases, or any clients
for that matter? I have brought my personal stove. I have to keep a
stock of kerosene. PHC does not supply me all these things. Immu
nization and physical examinations and IUD insertions cannot be
done in this place. First of all, this building does not even have the
looks of a clinic, nor the atmosphere. It is now 11:45 a.m. You please
wait till 1:00 p.m. and see how many clients come.
ANM: I do not have medicines. You please try what I have said. Af
ter your son-in-law comes, better take the child to the PHC. The big
doctor will examine him and give him medicines.
Man: Why do you say that? Is he in danger?
t.
ANM: No, no, not dangerous. It is always better to show him to a
doctor.
The man and woman left the subcenter.
Case 1: Diarrhea and Vomiting
a-'-'
Even before the above conversation had ended, an old man and a
young mother carrying an infant entered the clinic. The ANM ad
dressed the man.
if.
tr
ANM: Ram Ram, Dada! [Greetings, elderly person!] What is wrong? You
seem to have come with your granddaughter and great grandson.
T
I
I
Examining the child's eyes, skin, and stomach and checking his
pulse, the ANM asked how many times he had vomited and how
many times he had had a loose bowel movement.
IF
Man: Many times, maybe seven or eight times.
ANM: Did you take him anywhere [else] for treatment?
s
ANM: I was very much here, I had bolted the door from inside. See,
I have visitors (pointing to the researchers), and where will I go leav
ing them? What have you been giving the child?
Man: Only milk.
ANM (addressing the mother): You boil and cool water. You take a
small cup and add one spoon of sugar and a little salt, mix it well,
and start giving that to the child.
Man: We will not give all that because the child is vomiting. Every
time he vomits, he is having so much exertion. Give some medicines.
ANM: What problems do you have?
Client: I do not have any problems, but my children have.
ANM: What are their problems?
Client: This child is my eldest son. I k is not eating and is complain
ing of stomachache, and the other two children have skin problems.
The ANM pressed the child's abdomen.
K'
Man: No, we thought it was indigestion and it would stop on its
own. This morning the child looked weak and inactive, and there
fore we came to you.
Man: These children who were playing said your clinic had not
opened.
Case 2: Stomach and Skin Problems
Soon afterward a mother came into the subcenter with three small
children.
Man: My great grandson is continuously vomiting and having loose
bowel movements since last night. So we have come here.
ANM: Why did you not come early? You are coming at 12:00 noon.
What were you doing all this time?
ANM (with an expression of relief): The child is suffering from dehy
dration. I do not have ORS [oral rehydration solution] packets. The
child needs intravenous [rehydration].
■ B
■
ANM: Your son has worms in his stomach. You give this medicine
tonight, [and] he will become all right.
I
She gave the other two children some ointment in a piece of paper.
r
ANM (to the mother): You please apply this ointment after taking
food, and see that they don't put their fingers inside their mouth.
You apply this for three days and come back and show them to me
again.
I
After giving this advice and the medicine, she sent the client
home. By then it was almost 1:00 p.m. The ANM told the observers
that she did not think anyone else would come.
T
I
ANM: I will close down the clinic and we will go around the village.
I have a few cases for motivation and follow-up as well. Are you
interested in accompanying me?
108
Provider-Client Interactions in Madhya Pradesh
Sandhya Barge • Lakshmi Ramachandar
r
ANMs and Home Visits
r-
As mentioned at the outset, the team observed a total of 210 home
visits, or approximately 35 visits with each of the six ANMs. In gen
eral the ANMs appeared to have good relations with the villagers,
although there was likely some degree of selection in terms of whom
the ANMs chose for interaction. The following cases illustrate some
of those encounters.
I
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109
V^oman: She is running temperature and is complaining of severe
pains. Good thing you came. Are they doctors? (indicating the ob
servers) Ask them to come in and examine her.
ANM: No, no, they are not. I will come and examine her.
The ANM went inside to examine the woman's daughter-in-law,
who had had a laparoscopic procedure two days earlier. The daugh
ter-in-law was running a fever and had severe pain.
ANM (to client): Since when are you having the pain and fever?
Case 1: Motivating for Sterilization
Client: Soon after the operation I vomited, but 1 was discharged on
the same night. I am having temperature and severe stomach pain.
An ANM stopped near a house and called to her client from outside.
The ANM touched the woman's forehead, checked her pulse,
and examined the wound.
ANM: Tulsibai! Oh, Tulsibai!
■
Tulsibai came out and stood near the door, smiling at the ANM.
ANM: 1 will right now give you medicines for fever and pain, but
tomorrow morning, if you still have pains, 1 will come and take you
to the PHC or Vidisha Hospital.
-
ANM: Okay, please listen. I came to tell you there is a family plan
ning operation camp on the 20th. The vehicle will come at 10:00 a.m.
at the main entrance, near my subcenter. You must come. I have come
to inform you.
I:
Client: I know about it.
ANM: Did my colleague come and tell you?
Client: Yesterday doctor sir [the MPW] came to give immunization.
He told me about this.
I'
I
ANM: Are Savitribai and Ramadevi around here?
Client: They were here, but they have gone out somewhere.
v’i
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Case 2: Laparoscopy Complications
ANM: Oh, Krishnabai!
An old woman opened the door.
ANM: You please take these two tablets in the night after dinner
and again two in the morning after breakfast. There is no need to
worry. Take rest and I will come and see you again. (Turning to I ho
old woman) Please don't give her any spicy or solid food because she
is having fever. Give her only bread and milk or tea.
The ANM then left the house with the researchers.
ANM: If you meet them, inform them about the date. I will once
again come personally.
The ANM proceeded to another house for a follow-up visit of a
laparoscopic case. On reaching the client's doorstep, the ANM
knocked loudly on the door and shouted the client's name.
The ANM left the team and rushed back to the subcenter. She
soon returned with paracetamol and ibuprofen tablets.
•
I-
£•
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ANM: I have two more houses, but I have to go back to Vidisha. If
you don't mind, could you please drop me off in your jeep?
The team obliged her and gave her a lift. The visit had come to a
close at 4:00 p.m., and the team headed out of the village, with the
ANM, toward Bhopal.
A Visit to a Peripheral Village
ANMs have great difficulty in visiting all of their assigned house
holds, mostly because of the significant amounts of time lost in com
muting and other activities. They are particularly likely to neglect the
more distant, peripheral villages of their areas. One of the ANMs took
ANM; Ka»i Ram, Masi! [Greetings, aunty!] How is y,our daughter-inlaw?
•
110
Sandhya Barge • Lakshmi Ramachandar
Provider-Client Interactions in Madhya Pradesh
the observers to a remote village to demonstrate the difficulty of pro
viding services there. The following episode exemplifies the problems
that arise with clients in such villages.
The road leading to the outreach area was full of ups and downs
in this very hilly region. The ANM told the observers that the vehicle
would not be able to go all the way to the village because the road
was too narrow and heavy rains had made it impassable. The party
trudged 3.5 kilometers through thick jungle to reach the village.
As the team entered the village, some women were collecting
water at a public tap. Smiling, they left their pots and approached
the team. One of the women pointed to the ANM.
Woman: You have not come since a long time, and the doctor [male
worker] has not come either.
ANM: I had gone on leave for two months, so I could not come.
Woman: No, no. It is not since two months—since six months—you
have not come. Your colleague [male worker] also did not come.
What, both of you applied for leave together?
I
V
The observers were aware that the ANM was trying
trying to
to shift
shift the
the
focus of the discussion by requesting the women to make tea. The
ANM had deliberately chosen this village to show the team how dif
ficult it was to reach some villages. In the process, she found that she
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Client: Why should 1 come to the PHC just for this? You can remove
it now.
ANM: No. Some instruments are needed to remove it. 1 don't have
them now. I did not insert it, so I cannot remove it.
The team walked away from the client's house. The observers
later learned that the IUD had been inserted by the LHV a month
earlier. When they inquired why the ANM had not inserted it, she
said that she did not feel confident with the procedure. Her lack of
confidence was due to two failures that had occurred earlier in one
of her villages. She had therefore asked the client to go to the PHC
for the IUD. Otherwise she would not have promoted the IUD at all.
At the house of the next client the ANM stopped for only a
minute. The client was seated outside her house. The house was small,
with mud walls and a thatched roof, suggesting that the woman was
of lower socioeconomic status.
ANM: How are you?
K-
s
The client did not respond.
ANM: [At the] end of this month 1 will come with my colleagues
and immunize your child. Now I am going.
was exposing herself to criticism by the villagers. With frustration
showing on her face, she turned to the observers.
ANM: We made a mistake in coming to this village. I should have
taken you to another village.
ANM: If this is your problem, you please come to the PI 1C and get it
removed.
I
ANM: No, I will tell you later. These are our guests and they have
come from Bhopal, and why don't you give us some tea for the guests
instead of complaining against me?
Woman: With pleasure. Why only tea? They can have lunch with us.
Client (obviously angry): Yes, I have very much problem. I have se
vere backache and profuse bleeding, and I don't want this CopperT. Only after this insertion did all these problems start. I did not
have back pain or bleeding previously. You please remove it now!
■
f
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Nonetheless, she referred to her notebook to check on her list of
clients. She then proceeded to one of the houses. A child was stand
ing outside, and so she instructed the girl to go tell her mother that
"Sister has come." The client, Chandanbai, came out carrying a baby
boy in her arms. The ANM greeted her.
I
ANM: My colleague has inserted Copper-T for you last month. How
do you feel now? Are you having any problems?
II
Client: If you say the end of this month, I assume it is next year that
you will come.
The client was visibly upset and evidently wanted to say some
thing more as the ANM was walking away. On seeing this, the re
searcher approached her.
Client: This sister does not come at all to the village. She always says
she was on leave. Even if she does come, she does not come to my place.
I
At this point the ANM pointed to her watch and told the ob
servers that it was time to head back to the main road, as it was al
ready 4:30 p.m. As the team started back toward the road, the ANM
hurried over to another house and addressed the woman inside.
112
Sandhya Barge • Lakshmi Ramachandar
Provider-Client Interactions in Madhya Pradesh
ANM: Next month we are having laparoscopic sterilization camp. I
will let you know the exact date. You come and get operated. At the
end of this month I am coming here. At that time you must take TT
injection.
Despite the difficulty of reaching this remote village, it was clear
from the negative comments of the clients about the irregularity of
the ANM's visits that she had indeed visited this village in the past.
The villagers had received some medical services, although at very
irregular intervals.
One of the other ANMs also took the observers to another re
mote village. On the way she became lost and was unable to find the
village. After some time she asked some schoolchildren on the road
to direct her to the village. Upon entering the village she was met
with hostility from a group of men. One of the men pointed to her
figure (she was overweight).
Man: See that. If you would come out to our village sometimes, you
would not be fat like that. You would be slim as we are.
it
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Discussions with the Clients and the ANMs
R-'Our direct observations of provider-client interactions gave us use
ful information about the quality of care delivered by the ANMs dur
ing their home visits and other activities. Our discussions with cli
ents (without ANMs being present) gave us further insight into the
actions of ANMs. Having these two different types of data strength
ened our conclusions. Clients' statements, made during individual
interviews and group discussions, can be summarized as follows:
• Many of the women in the communities expressed satisfac
tion with the services received from the ANMs. This was par
ticularly so in the case of women in the more affluent house
holds of the most accessible villages.
• On the other hand, many women of lower socioeconomic sta
tus stated that the ANMs' services were few and irregular. In
one group discussion, two upper-caste women defended the
ANMs and their work, while six women from lower-caste
households disagreed.
• Many women felt that their ANM should inform them in ad
vance of her schedule and be much more regular in her visits.
SS'
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113
A typical comment was, "She doesn't inform us about her next
visit. She doesn't seem to have any schedule."
• In one group, the women said they knew all about family plan
ning from television and other sources, and that they were not
motivated by the ANM.
• The great majority of the villagers said that their subcenter
was almost always closed, so that it was largely useless as a
health care resource.
• Many women said that follow-up was very poor and that the
ANM told them nothing about the possible side effects of contra
ceptive methods, such as the IUD and sterilization. One ANM
told a researcher that they did not talk about side effects because it
would impair their chances of achieving the method target quotas.
• Some women objected to their ANM's using the home of the
thakur [upper-caste, wealthy landlord] for immunizations.
Some said that the ANM should go from house to house. Oth
ers suggested that the ANM rotate her visits among selected
houses. A typical complaint was, "Why is she sitting in one
house? She is very lazy."
• Despite their complaints about the ANMs' failure to provide
adequate services, the villagers did not appear to be concerned
that the ANMs were "outsiders." They did not suggest that the
ANM should be a member of their community. Nor did the
villagers question the ANMs' overall qualifications, although
they pointed out specific gaps in the ANMs' knowledge (or will
ingness to impart knowledge). The main reason for their dis
satisfaction was the ANMs' failure to provide regular services.
Bi
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Work Schedules of the ANMs
The schedules of the ANMs were severely affected by the fact that
five of the six lived in towns located a considerable distance from the
PHC areas they served. As shown in Table 6.2, the ANMs spent about
three hours a day traveling by bus from their homes to their work
locations and back again. They were supposed to maintain clinic hours
at the subcenters from 10:00 a.m. to 1:00 p.m. but did not strictly ad
here to those hours. During our observations they often arrived at
the subcenters at around 11:00 a.m. On days when they did not have
Provider-Client interactions in Madhya Pradesh
I
TABLE 6.2
Commuting and work schedules of six ANMs:
Vidisha District, Madhya Pradesh, 1994
ANM
A
B
C
D
E
F
Approximate
commuting time
between home
and PHC
per day (hours)
Approximate
commuting time
from PHC to SC
and villages
per day (hours)
Approximate
time spent
working in
villages per
day (hours)
5
1.5
2.1
4
4
5
5
4
1.0
1.0
2.4
1.6
1.0
1.3
1.5
0.0
2.1
4.6
4.5
4.4
3.9
4.6
4.7
No. of days
worked per
week
Sandhya Barge • Lakshmi Ramachandar
g-i,-.
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subcenter clinic activities, they made home visits in the villages. The
ANMs also had a number of other responsibilities at the PHC. Home
visits were usually made in the morning, extending into the after
noon if the ANMs did not go to the PHC. We found that the ANMs
had very few hours per week available for the home visits.
|
,
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Conclusion
The observations described in this chapter were carried out in situa
tions that represent some of the best-case examples of primary health
care in rural India. The two PHCs included in the study had doctors
in residence, and all the ANMs had 10 years of education and at least
five years of experience. Thus this study has not reported on the typical quality of care. Nevertheless, it has identified several factors that
prevent the system from delivering optimal services.
The quality of care we observed ranged from good quality and
good availability in the PHCs themselves to low quality and poor
availability in more remote villages. Between those two extremes was
the quality of care provided by the subcenters, which appeared to be
inadequate and irregular, except at two subcenters that were located
in somewhat better facilities. The wide range of quality and avail
ability of services in the subcenters demonstrates the central impor
tance of basic accommodations—the buildings in which the services
are provided. It is impossible to maintain even minimal standards of
quality of care without adequate facilities.
A major feature of the ANMs' activities was the heavy emphasis
on motivating selected women for sterilization and other family plan
ning services. The ANMs concentrated mostly on sterilization, in part
because they receive a direct cash reward for each acceptance, but
also because of the constant pressure at the PHC level to achieve their
targets. The program also had targets for immunizations, but these
seemed to receive less emphasis, and ANMs receive no cash incentives for immunization acceptors.
T'La inl-ar□ rFiUnfair
The
interactions between the ANMs and their clients that our
team observed provided strong evidence of the emphasis on steril
ization and, to a lesser extent, on other family planning methods in
the PHCs' work. All the ANMs expressed the view that their services
would improve if targets were eliminated. The low quality and infre
quent provision of services in the peripheral villages are especially
troublesome. They receive practically noMCH services and are often
neglected entirely during immunization campaigns. The few visits
they receive appear to be mainly for achieving sterilization and fam
ily planning targets. It is difficult to blame the ANMs for neglecting
the peripheral villages. During monsoon seasons they are practically
impossible to reach. Even during the dry seasons travel to many of
the villages is extremely difficult and time-consuming.
Caste appears to have played a major role in the differential quality of service we observed during the study. Centrally located house
holds and those belonging to members of upper castes appeared to
receive greater attention and service than other households. They were
able to offer the ANMs greater hospitality in the form of tea, sweets,
and other foods, such as fresh fruits and vegetables. The effect of caste
is thus closely intertwined with the effects of socioeconomic status.
We believe that the ANMs we observed were sincerely trying to
serve their assigned communities. These women came to their work
sites and performed their duties according to their understanding of
their responsibilities. Unfortunately, the strong focus on achieving
sterilization and other specific family planning targets had a distort
ing effect on their performance. The complaints of the women in the
peripheral village we visited illustrate how the emphasis on targets
leads to the neglect of some clients.
Considering the ANMs' performance in the light of Bruce's cat
egories for assessing quality of care, on the one hand we found that
the ANMs' interactions with clients were, for the most part, friendly
r.
J SO"z
ANM=auxiliary nurse-midwife; PHC=primary health center; SC=subcenter.
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116
Provider-Client Interactions in Madhya Pradesh
-
and effective. On the other hand, the amount of information that the
ANMs gave to their clients, particularly about the side effects of con
traceptive methods, was seriously deficient. The follow-up services
were also deficient, mainly because of the irregular home visit sched
ules kept.
The greatest problem our study has identified is the limited
amount of time available to the ANMs for client care. Each day they
spend several hours commuting to and from the PHCs. They must
then spend another one to two hours traveling to the outlying vil
lages. This schedule leaves only two or three hours at most for actual
client contact. During those hours they are able to contact only about
seven or eight clients. There is no way they can provide regular serv
ices to the large numbers of clients in their assigned areas, given such
time constraints. It is no wonder, then, that the ANMs neglect the
peripheral villages in their areas. They do not even have time to serve
adequately the people in the more accessible villages.
The quality of care at the PHCs we observed is quite good. Doc
tors are available during and after clinic hours, and the ANMs seem to
report to work regularly. In other areas, particularly where the doctors
attend the PHCs irregularly, the ANMs too are likely to spend fewer
days in their work areas. In such cases the coverage and quality of care
are likely to be much worse than the conditions described in this study.
<
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Bruce, Judith. 1990. "Fundamental elements of the quality of care: A simple
framework," Studies in Family Planning 21(2): 61-91.
Cleland, John, James F. Phillips, Sajeda Amin, and G.M. Kamal. 1994. The Deter
minants of Reproductive Change in Bangladesh: Success in a Challenging Envi
ronment. Washington, D.C.: World Bank.
Khan, M.E., Bella C. Patel, and R.B. Gupta. 1996. "Quality of family planning services
from provideds perspective: Observations from a qualitative study in Sitapur
District," Technical Working Paper. New Delhi, India: Population Council.
Phillips, James F., Mian Bazle Hossain, Ruth Simmons, and Michael A. Koenig.
1993. "Worker-client exchanges and contraceptive use in rural Bangladesh,"
Studies in Family Planning 24(6): 329-342.
Seidman, Myrna, and Marjorie C. Horn (eds.). 1991. Operations Research: Helping
Family Planning Programs Work Better. New York: John Wiley & Sons.
Simmons, Ruth, Laila Baqee, Michael A. Koenig, and James F, Phillips. 1988.
"Beyond supply: The importance of female family planning workers in ru
ral Bangladesh," Studies in Family Planning 19(1): 29-38.
Simmons, Ruth and Christopher Elias. 1994. "The study of client-provider interac
tions: A review of methodological issues," Studies in Family Planning 25(1): 1-17.
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References
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I
Women's Perspectives
on the Quality of General and
Reproductive Health Care:
Evidence from Rural Maharashtra
manisha gupte, sunita bandewar,
& Hemlata pisal
SV
I
7
There is a need to document women's perceptions regarding the qual
ity of their health care, including abortion services, since most stud
ies to date have approached this issue from the viewpoint of service
providers, policymakers, or the state (Jesani and Iyer 1995). Basic ma
ternal and child health (MCH) care, from both public and private
sources, has been grossly neglected in India. MCH services, which
are practically the only special program for women, receive a mere 2
percent of the national health budget. In fact, with less than 1 percent
of the gross domestic product currently allocated for health services,
there is a large gap between health needs in India and the public in
frastructure intended to serve them. The number of health workers
and the infrastructure available for even the existing limited services
are inadequate and of poor quality. Added to this deficiency is a bias
favoring urban areas in health care delivery (Duggal 1995).
Whereas most government-run primary health centers (PHCs) lack
functional equipment and trained personnel to carry out medical ter
minations of pregnancy (MTPs), the private sector, which is often char
acterized by inadequate equipment and insufficient facilities for such
procedures, engages in profit-making through unstandardized treatment
and charging practices (Nandraj 1994). In fact, the use of unnecessary
and even hazardous procedures and drugs has been found to be far more
common in private clinics than in government clinics (Phadke 1994).
117
lib
Women's Perspectives on Quality in Rural Maharashtra
Implementation of the statutes of the MTP Act1 has been geo
graphically uneven. Women not only find the services inaccessible,
but are also reluctant to use them because of the lack of confidential
ity and anonymity (UN, Population Division 1993). The ratio of ille
gal to legal abortions is estimated to be anywhere between 3:1 (Karkal
1991) and 8:1 (Jesani and Iyer 1993). Numerous recommendations
have been made in the recent past for improving women's access to
safe abortions; they include upgrading the health infrastructure, train
ing providers, and increasing public awareness and information dis
semination (Parivar Seva Sanstha 1994).
Women's access to all health services is extremely limited in the
region of Pune District, Maharashtra, the area of our study. Women
have been found to suffer more than men from chronic ailments, on
which their households have been reluctant to spend money for treat
ment. Neither landowners nor the state has been willing to compen
sate women for health problems related to employment in the land
owners' fields or on government sites for drought relief. Vaginal white
discharge, prolapsed uterus, backache, and problems resulting from
the Copper-T intrauterine device (IUD) and sterilization have gener
ally gone unheeded (Gupte and Borkar 1987). Women use PHCs mainly
during their reproductive years; the health care needs of girls are largely
neglected. PHCs' hours of operation frequently conflict with women's
work schedules, and the inconvenient location of PHCs have made
them inaccessible to many villages in rural areas (Awasthi et al. 1993).
The concept of quality of health care (QHC) has been developed
as a tool for identifying health needs and assessing health services.
In the late 1980s Donabedian advanced the QHC concept (Donabedian
1988), and Simmons, Koblinsky, and Phillips (1986) and Bruce (1990)
applied it to the assessment of how clients are treated in family plan
ning programs. Protocols have been developed to assess whether qual
ity has been considered—along with quantity, accessibility, and the
distribution of health care delivery—in evaluations of health services
(Roemer and Montoya-Aguilar 1988). In the study reported here, we
have used the QHC concept to understand women's needs in a vari
ety of situations in which they seek health services, including abor
tion services. The study documents their choice of providers in those
situations and women's feelings about both public and private health
services. The study took place in a rural area of Pune District,
Maharashtra, between April 1994 and March 1996.
Manisha Gupte • Sunita Bandewar • Hernlata I’isal
119
Methodology and Sample
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As part of a larger qualitative study on rural women's perceptions
T' '
and experiences related to abortion, participants in
i our focus groups
were interviewed about their desired QHC, choice of providers, and
their views about public versus private abortion services. We used
rank-ordering and a semistructured questionnaire to collect this in
formation. We selected six villages on the basis of their access to health
services, their size (ranging from 1,500 to 3,500 inhabitants), and ac
cess by transport to nearby towns. The intention was not to do a com
parative analysis, but rather to record the qualitative nuances in the
narration of women in differing situations when asked to consider
their specific health needs. Collecting information about a sensitive issue such as abortion was not difficult because we had established rapport with women in the region over a period of eight years. We identified as contact persons women with whom we had long-standing
relationships; they helped to authenticate the collected data and served
as a voice of conscience to us as we went about collecting information.
During monthly meetings with the focus groups, which took
place over eight months, we documented women's needs for health
care delivery. On the basis of those discussions, we drew up a list of
21 QHC indicators based on the women's expressed concerns. The
list was field-tested with the women and subsequently refined. As
we spoke with the women, we realized that the QHC they desired
was not a fixed entity, but instead depended on their social circum
stances and specific health needs. Our respondents wanted situationspecific services for general health care, for deliveries, and for abor
tions. Among women seeking abortions, the needs of those who were
married differed somewhat from those who were not.
We believed that the QHC for abortion, if considered in a
vacuum, would give an inaccurate picture of women's needs. When
women choose a few indicators as a priority for abortion services,
they may do so at the cost of omitting other indicators that they also
feel are important. To correct any artifacts in our data that rank
ordering might create, and to understand women's needs related to
abortion in real-life situations, we decided to ask them not just about
their needs related to abortion services but also about their needs for
general health care and obstetrical care, both of which are consid
ered socially acceptable needs. Our assumption was that in the latter
*
w
'J
r
I r
£
ft-'
_/•:-
I
I
II
g;
fe'
1
"I
f.
fe-’ •'•■■
0
120
Women's Perspectives on Quality in Rural Maharashtra
two areas they were freer, at least theoretically, to choose good QHC.
By introducing the topic of abortion within this broader context, we
hypothesized that women would feel more comfortable expressing
their underlying feelings when they talked about abortion services.
From the focus-group discussions, we learned that when seek
ing any kind of health service, all women had concerns about cost
and affordability. Some of them spoke of the distance and time in
volved in seeking health care, mentioning the amount of money they
would have to pay for transport or how much they would lose in
wages if they spent too much time on medical treatment. We there
fore decided to treat opportunity costs and affordability as separate
and important concerns, rather than as merely one indicator of QHC.
In the survey that followed the focus-group discussions, we
asked our respondents several sorts of questions: To understand
women's preferred choice of providers when seeking health care for
various needs, we asked which services they used, or preferred to
use, for minor illnesses, chronic ailments, health emergencies, ante
natal and postnatal care, delivery, sex-determination during preg
nancy, gynecological problems, intramarital abortion, and extramari
tal abortion (defined as abortion by a nonmarried woman, whether
deserted, widowed, or never married). To understand the linkage be
tween the accessibility of services and choice of provider, we asked
them about public and private services that were available in their
villages, at the taluka (subdistrict) level or in the neighboring towns,
and in the district headquarters. We also recorded the women's rea
sons for choosing public or private health services. Cost and
affordability were better understood in this context.
For the survey portion of the study, 61 of the 67 ever-married
women who had regularly been part of our focus-group meetings
were interviewed about QHC, 49 were interviewed about their choice
of providers, and all 67 women were interviewed about their choice
between public and private abortion services. The interview processes
are described in detail in the findings section.
Care was taken to include both cohabiting and noncohabiting
women from various caste, class, and age groups. About half (49 per
cent) of the respondents were Maratha women, the dominant caste
(numerically, economically, politically, and culturally) in the region;
but the sample also included significant numbers of women from
scheduled castes and resettled nomadic tribes. Muslims and Jains were
Manisha Gupte • Sunita Bandewar • Hemlata Pisal
also included in the sample. The majority of women were between
20 and 40 years of age. The youngest respondent was 17 years old,
the oldest 60 years.
I
I
B■■
I
I '
I
7^
WIP- ■
ft
J _
B
II
I
The 61 ever-married women whom we interviewed about QHC were
each given a set of 21 cards in random order, each of which spelled
17f-y
j I--
I
ft
fr-
I
if
? I- ■
Because the first two instruments involved the use of cards for
rank-ordering preferences, we had to select literate women from
among our focus groups. The respondents were selected from all six
villages of the research project. The 49 women who were interviewed
about their choice of providers participated in all three sections. Be
cause the three interviews were lengthy, it proved impossible to in
terview all 67 women for all three sets of data. In all three sections,
the respondents freely expressed their feelings and opinions. Their
narratives have been classified by content, and representative narra
tives are presented in the following sections at appropriate places. In
recording and translating their comments, we have taken care to pre
serve the idiom of their language.
Perceptions of QHC
■
I
■ ?
121
■
?
out one indicator of service quality. The respondents were asked to
identify and rank-order the three most important indicators of serv
ice quality for each of four types of health care need: general health
care, obstetric care, medical abortions within marriage, and medical
abortions outside of marriage. Respondents were asked to consider
each type of health care need, regardless of whether they had ever
used this service themselves. The three highest-ranked indicators were
recorded for all four situations for each respondent. After the woman
had chosen the three indicators, she was asked to place them in or
der of priority. To confirm her selection and to understand the logic
of her choice, the respondent was then asked to explain why she had
chosen those indicators.
Because abortion is a sensitive subject and extramarital abortions
are difficult to obtain in India, we did not ask respondents whether
they had ever had an extramarital abortion. For the sake of simplifi
cation, we classified all conceptions of single women—whether un
married, widowed, or deserted—as extramarital and all conceptions
of currently married, cohabiting women as intramarital. Our reason
for doing so was that women who cohabit with their husbands have
122
Women's Perspectives on Quality in Rural Maharashtra
easier access to abortion than single women. Cohabiting married
women who become pregnant as the result of an extramarital rela
tionship can, in all probability, pass off the pregnancy as resulting
from intramarital intercourse.
Table 7.1 presents the results of the rankings, cross-tabulated by
the four situations. For each situation, the first column gives the added
score (ranks 1 + 2 + 3) for each indicator. The "ranked first" column
shows the number of women who ranked each indicator as the most
important factor in QHC for that particular situation. Together the
two columns reveal which indicators the respondents considered to
be most important in a particular situation, as well as the placement
of other indicators in the rankings. The highest score in each column
is in bold type.
The rankings indicate that the women's priorities for QHC var
ied according to the situation in which they might seek health care.
Two indicators, presence of a woman doctor and empathy or con
cern of doctor, received high cumulative scores in three situations,
whereas many others (e.g., easy access, safety and reliability, roundthe-clock service, and equipment and machinery) received high cu
mulative scores in two situations each. Another interesting pattern
revealed by Table 7.1 is that in three of the four situations (general
health care, delivery care, and abortion outside marriage), the firstranked indicator received that ranking from substantial numbers of
women, whereas in the case of intramarital abortion the first-ranked
indicator was so ranked by only seven women. The contrast between
some of the QHC indicators for abortion and nonabortion services helps
one to understand the complex social milieu in which women's sexu
ality and their decisionmaking (or lack of it) about abortion take place.
; W
O'1
Among women seeking general care, the indicators receiving the high
est cumulative scores were, in descending order, the attention and
concentration of a doctor when examining and treating a patient,
round-the-clock service to deal with emergencies, easy access and con
veniently located service, and—receiving equal scores—the doctor's
respect for the patient and readiness to listen to her description of
symptoms, the doctor's empathy for the patient, and the cleanliness
Rankings of quality of care
indicators in specified situations*
General
health
care
■ F-'
I
Indicator
■
■
::
li
z-
- i.
S'
II
I
£
Top 3
Easy access,
nearby services
15
6
Quick service, quick return
2
One visit, no repeated visits 3
Short waiting period
Doctor’s attention,
concentration
Obstetric
care
Abortion
within
marriage
Abortion
outside
marriage
First
Top 3
First
Top 3
First
Top 3
First
7
2
0
1
18
4
5
4
11
0
1
2
4
11
1
1
4
4
6
11
1
5
1
1
6
5
5
3
7
17
3
1
1
1
5
■
Safety, reliability
Effective treatment,
quick relief
10
2
2
1
7
13
11
13
3
0
8
5
11
10
0
1
4
4
1
18
6
8
4
0
0
0
6
0
2
0
0
11
27
18
6
11
1
1
5
2
183
3
0
61
6
7
183
Sex of doctor immaterial
Respect for client/listens
Doctor’s empathy,
concern, counseling
Boarding facilities
Adequate staff to clean up
Round-the-clock service
£
r-
■ I ■
Drugs available
Equipment and machinery
Confidentiality
Discreet location
Husband's signature
not required
No response
Total no. of responses
5,
i
• &
II
I■
t
17
16
2
1
7
1
Cleanliness
Courteous behavior
from staff
?
5
29
9
3
13
8
Presence of woman doctor
11
3
5
■!
I
123
TABLE 7.1
Importance of indicators of quality of care in four health-care-seeking
situations: Six villages of Pune District, Maharashstra, 1994-96
I
I
I
■ i
General Health Care
Manisha Gupte • Sunita Bandewar • Hemlata Pisal
F-
1
0
12
2
8
0
11
2
2
1
11
7
3
1
3
0
9
4
3
1
0
10
4
0
6
0
0
12
3
1
6
1
0
2
7
7
1
3
1
0
13
1
7
7
15
2
7
5
0
3
2
5
1
3
5
0
2
0
4
2
61
21
15
183
7
5
61
6
4
10
3
3
0
35
13
27
8
14
5
6
2
183
61
a For the “ranked in top 3’ columns, numbers represent the number of
ot respondents who considered
each specified indicator to be one of the three most important QHC indicators. For “ranked first"
scores, numbers represent the number of respondents who ranked each specified indicator as tfie
single most important. Numbers in bold type represent the choice of the largest number of women in
each column
u
Women's Perspectives on Quality in Rural Maharashtra*
124
Ifl
of the facility. Other indicators receiving somewhat lower but still
high cumulative scores were the availability of boarding facilities, ef
fective treatment and quick relief, and the presence of a woman doc
tor. The quality indicator for general health care that was ranked first
in importance by the largest number of women was the attention and
concentration of the doctor. Much smaller numbers of women ranked
cleanliness, easy access, respect for the client, and round-the-clock
service as the single most important indicator.
The following comments are representative of those made by re
spondents when they were asked to describe their concerns about gen
eral health care:
II
9
IB
■■b
I
How will the doctor know about our illness if he isn't paying atten
tion? Nothing will get into his head. He won't even know which
injection he's giving. In case we don't get better, we'll keep thinking
that it was because he wasn't concentrating. We'll feel that maybe
he cheated us out of our money.
A doctor may have his timings [schedule], but does an illness come
that way? It's their duty to attend to us at all times. An urban pa
tient can go to another doctor, but a villager doesn't have transport.
Doctors don't pay attention to poor patients. They're not social work
ers any more; they've become businessmen.
If the doctor doesn't listen to our complaints, we feel all tensed up.
It further adds to our illness. We're already so tired waiting in the
queue. If he listens, it soothes us.
At least the patient should get food in the hospital. Attendants can
stay hungry. What if the patient's anesthesia wears off in the middle
of the night and she asks for food? Sometimes there's no food avail
able within a mile of the hospital.
fe; ■
ly
IK.
11
I
b
J
1?'-
Obstetric Care
The indicator for obstetric care that received by far the highest cumu
lative score was adequate staff to clean up the labor room. Other indi
cators given high cumulative rankings for this health situation were
easy access and convenient location, round-the-clock service, presence
of a woman doctor, safety and reliability of treatment, boarding facili
ties, courteous behavior from staff, adequate equipment and machin
ery, and cleanliness. The indicator considered to be most important by
the largest number of respondents was easy access and convenient lo
cation of the delivery service. Ranked first in importance by smaller
s
s
Manisha Gupte • Sunita Bandewar • Hemlata Pisal
125
numbers of women were adequate staff to clean up, round-the-clock
service, safety and reliability, and the presence of a woman doctor.
Respondents made the following comments:
Heart attacks and childbirth can Ihappen at any time. We must have
a clinic close by. Someone can die just because of this.
They make us clean up the labor room after our daughters deliver
What do they charge us for? What's the use of the nurses and
[helpers]?
The first childbirth hurts, doesn't it? If we scream, they shout and
slap us. They say, "You didn't feel any shame when you got the thing
in there. Why are you shouting when it's coming out now?" They
don't give us any information. If they don't pay any attention, we're
forced to keep quiet and stop asking.
Abortion Within Marriage
When women seek abortions within
marriage, they have legal access
to the service. Nevertheless, they may experience feelings of guilt and
be bothered by the fact that staff at public services ask for tire husband's
approval and exert pressure on the woman to use contraception after
the abortion. The quality-of-care indicators that our respondents chose
in this situation were quite telling. The indicator receiving the highest
cumulative score was that a husband's permission not be required.
Other indicators receiving high cumulative scores were quick service
enabling a quick return to the home; safety and reliability; adequate
equipment and machinery; courteous behavior from staff; only one visit
required; and empathy, concern, and counseling from the doctor. Not
requiring the husband s signature received the highest individual score.
Characteristic comments on this situation were:
If a husband refuses to sign, what is the woman to do? Your hus
band may turn back and say, "Whose bundle of sin were you carry
ing? You dropped [aborted] it because it wasn't mine." Or he may
say, "Why are you dropping my child? I want it to stay." Who knows
what he will say! Often husbands don't use a contraceptive and don't
let the wife use it either. He says, "You will sleep with others if you
are free." Sometimes you don't tell your husband that you're emp
tying it out. The doctors shouldn't hold us back for his [the
husband's! signature.
We should be able to go back [home] immediately. The family won't
send us if the travel and stay takes many days. The housework has
126
Manisha Gupte • Sunita Bandewar • Hemlata l isai
Women's Perspectives on Quality in Rural Maharashtra
to be done, and they won't like to spend much on my needs. Be
sides, if I haven't told my mother-in-law, she will begin to suspect.
The staff abuses us. They insult us for not using a Copper-T. If we
get pregnant soon after delivery, they say dirty things [about us].
The doctor should explain to the woman that repeated episodes of
dropping [abortion] are not good. Sometimes young girls get preg
nant because they are ignorant or rebellious. Sometimes there is force.
Someone may have done it [had sex] for money, because of her pov
erty. She can become weak. A doctor knows these things. He should
explain [them] to her.
Abortion Outside of Marriage
I
< I
t
Given the social circumstances under which an unmarried, widowed,
or deserted woman seeks an abortion, it is not surprising that respon
dents to our survey gave secrecy precedence over all other consider
ations when asked which indicators were important for women seek
ing extramarital abortion care. Confidentiality on the part of the doctor
received the highest cumulative score and was the first-ranked score
among the indicators of quality. Also receiving high cumulative scores
were a discreet and distant location for the abortion service, not hav
ing to obtain a husband's permission, a short waiting period, empa
thy and concern from the doctor, only one visit being necessary, the
presence of a woman doctor, and the availability of drugs.
Characteristic of comments about this situation were the following:
If she [a single woman seeking an abortion] has to wait for long, she
may meet people she knows. Then the news will be all over the place.
People will say, "She was perfectly all right. Then why has she been
taken to the hospital? Why hasn't the family taken anyone else
along?" The story will sprout too many branches. If the woman re
turns [home] quickly, nobody will get suspicious.
If we go to the chemist for the drugs, he will know what they are
used for. He may talk around. There are barely one or two medical
stores, even in the taluka place, and everyone knows everyone. If
we move around for medicines, we're bound to run into our rela
tives and villagers. Then the news will be out. So all the drugs must
be available with the doctor.
If she doesn't have a husband, from where can she get one to sign
[the permission form]? Doctors shouldn't ask these questions.
Choice of Provider
I ■
I
I'
i
•
The woman is already so harassed. If the doctor talks about her prob
lem to others, she won't get a husband later on. She may even be driven
to suicide. The whole family, [including] her brothers, will lose face.
If the doctor keeps the confidence, she may have the courage to come
back to him for other illnesses. Sometimes a woman gets weak and ill
after the emptying out. She may have to stay indoors for a while. In
such a case, the doctor should find excuses on her behalf.
I
fe
ir;
i
i
i
Why should a doctor betray the woman? Hasn't he earned his food
and drink from her? It's his need too. He frees her from her problem
only after she has paid his fees.
For the section of the survey on women's preferences with regard to
a provider, we gave the 49 respondents a set of 10 cards in random
order. Each card mentioned one kind of provider, either a person or
an institution. At one end of the spectrum were a traditional healer
and self- or folk-remedies; at the other end, public and private hospi
tals. The respondents were asked to select their first choice of pro
vider for nine situations in which women typically seek health c<ire.
Because the category of general health care was too broad to be use
ful, we divided it into three subcategories: minor health problems,
chronic health problems, and emergencies. Likewise, we divided re
productive health concerns into six subcategories: antenatal and post
natal care, delivery care, gynecologic disorders, sex-determination
tests, intramarital abortion, and-extramarital abortion. After choos
ing their preferred provider for each type of care, the women were
asked to explain their choices and the answers were recorded.
Table 7.2 presents the participants' responses regarding the type of
provider they would prefer in each situation. Numbers in bold type rep
resent the choice of the largest number of respondents in each situation.
No one should know that we went to the doctor. Then there won't
be any gossip about the woman. Our relatives mustn't get to know
anything [about this]. The hospital should be at a place where we
won't meet them. Everything must be done in the utmost secrecy.
Minor Illnesses
A male doctor deliberately asks embarrassing questions. We feel shy
with a male in such a situation. If there's a lady doctor, we can talk
freely and find an early solution. It's so necessary in this case.
For minor illnesses the first choice of provider for the largest number
of women (39 percent) was self-medication. Twenty-four percent said
they preferred the public health services, either their own PHC or PHC
I
!
I
Manisha Gupte • Sunita Bandewar • Hemlata Pisal
Women's Perspectives on Quality in Rural Maharashtra
128
TABLE 7.2
Choice of provider in nine health-care-seeking situations:
Six villages of Pune District, Maharashtra, 1994-96
Provider
Inhaling steam is good for colds. For colds, we use the leaves of the
saatap plant.
[
Number of respondents choosing
provider in a specified situation
- I
Abort. Abort.
Sex within outside
Gyn.
Minor Chron. Emer- ANC/ Deliv
ery disorder deter, marr. marr.
illness illness gency PNC
I,
Self-medication/
treatment
19
0
0
0
3
2
0
1
0
Folk/traditional
remedies
4
0
0
0
0
6
0
1
0
0
0
0
0
0
0
0
o
0
Rituals
Nonqualified
village doctors
129
^3. .
We take medicines from that Laal Topdya [Red Helmet, a private,
nonqualified practitioner]. He comes to the village every week on
the bazaar day.
If the fever is infectious, we'll go to the PHC. They have good im
munization services. Not to the private doctor. They are out there to
loot our money.
J'"
Chronic Illnesses
9
4
3
2
0
0
0
o
o
Qualified private
doctors (towns)
5
5
17
7
9
20
7
23
30
PHC (own)
4
2
5
14
18
6
0
5
3
PHC staff
(ANM/nurse)
8
0
3
14
8
5
0
3
0
PHC, taluka
0
2
5
7
3
0
8
8
Govt, hosp., Pune
0
3
32
2
0
1
4
2
4
3
Private hosp.,
Pune/Bombay
0
3
16
1
2
3
33
3
1
Do not know/
not sure
0
0
0
3
1
0
5
0
1
Would not seek
service
0
0
0
1
0
0
0
1
0
No response
0
0
1
2.
0
0
2
0
3
Total number
of women
49
49
49
49
49
49
49
49
49
Note: Numbers in bold type represent the choice of the largest number of respondents in each situation.
ANC/PNC=antenatal care or postnatal care; ANM=auxiliary nurse-midwife; PHC=primary health center.
staff. Eighteen percent would go to a nonqualified village "doctor"—
normally a visiting registered medical practitioner of allopathy,
ayurvedic medicine, homeopathy, or another speciality, but not neces
sarily a person with a medical degree—whereas 10 percent preferred a
qualified private doctor in a nearby town. Only 8 percent said they
preferred to use traditional folk remedies for curing minor illnesses.
Representative of respondents' comments were the following:
I'll buy a pill and take it myself. Where's the money to go to a doctor?
Just look at me; my back keeps paining. I give it hot fomentation. If it
gets too bad, they'll have to take me to the doctor, won't they?
I'K
!
I
B ■
r
•
E
I
I
I
I
I
-
i
iI
i
ft
f
I
Respondents regarded tuberculosis, arthritis, and asthma, among
other illnesses, as chronic. When asked about their preferred choice
of provider for chronic illnesses, 65 percent selected the government
hospitals in Pune. Much smaller proportions chose other providers
ranging from qualified private doctors in nearby towns to private hos
pitals in Pune and Bombay.
Typical comments were the following:
We'll go to Sassoon [the district civil hospital]. You don't have to
spend there, except for the case paper [an official document]. 7 here
aren't enough facilities in the PHC. But in the big government hos
pitals, there's everything you need.
When you see symptoms of TB [tuberculosis], you shouldn't waste
time on home remedies. You must go to Sassoon or to the Chest Hos
pital in Pune. Why go to private doctors and waste money when
we'll surely get cured here?
Emergencies
In response to a question about their provider preferences in case of
emergencies, two-thirds of the respondents selected qualified private
doctors in nearby towns or private hospitals in Pune or Bombay as
their first choice. One-fifth chose local public health services, includ
ing their own PHC and its staff.
The following comment was characteristic:
When there's a heart attack, we should find whoever is available
first. After that, one shouldn't hesitate to go to a good private doc
tor who has all the facilities. If we go close by [to a nearby facility],
they will anyway ask us to take the patient to a bigger place. Better
not to waste any time.
Women's Perspectives on Quality in Rural Maharashtra
130
Man is ha Gupte • Sunita Ban dewar • Hem la la i’lsal
-
Antenatal and Postnatal Care
[I
IE
I
Fifty-seven percent of the respondents preferred public health services,
either their own PHC or PHC nurses or auxiliary nurse-midwives
(ANMs), for antenatal and postnatal care. Fourteen percent chose quali
fied doctors in nearby towns, and 10 percent preferred the taluka PHC.
One woman stated:
We'll go to a gynecologist in the town or in Pune. They don't pay
any attention to you in the PHC.
There are good remedies with leaves and herbs for these problems.
A woman from a nearby village can also treat a prolapsed uterus.
Sex-determination Tests
I
Prediagnostic tests for the purpose of determining the sex of a fetus
I
The PHC staff come to the village every month and check us up.
Then they give tablets and TT [tetanus toxoid] injections. We don't
have to go anywhere else.
|
are banned in India. When a doctor passes on information about the
sex of a fetus to a pregnant woman or her family, he or she is engagin£ in an
act- Nevertheless, sex-determination tests are available to people through private, illegal channels at high cost. Son preference is deeply rooted in India's patriarchal social structure, and it
is so strong that couples are willing to incur heavy debt to pay for
I
sex-determination tests, followed by a second-trimester abortion in
J
*
.
Others suggested that the government facilities were fine for nor
mal pregnancies and postnatal care, but if there were complications
they would want to have a private doctor:
W:- '
If one has no problems in pregnancy, we can go to the PHC. But if there's
pain or any other problem, then we have to go to the private doctor.
Deliveries
K•
the event the fetus is female. Four-fifths of the respondents in our
our
sample
said
they
would
go
to
a
private
hospital
in
Pune
or
Bombay
----- r---------- —j
w«
in Pune or Bombay
or to a qualified private doctor in a nearby town to obtain a sex-determination test during a pregnancy. Equipment required for prenatal
Sixty-nine percent of our sample preferred the public health services
for their deliveries, most of them choosing their own PHC. Twentytwo percent preferred to have their deliveries attended by a quali
fied doctor in a nearby town or to deliver at a private hospital in Pune
or Bombay.
I
|
diagnostics might be available in government hospitals, but sex-determination tests would not be conducted there. None of our respon-
ill
dents had availed herself of sex-determination facilities in the public
sector. Five respondents did not know whether sex-determination
tests were available, and one woman said that such tests were banned.
1.1
1
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After trying to deliver her with a local dai [traditional midwife], we
go to the rural hospital. Time is very important in this case. It's an
unnecessary waste of money going to a private hospital. If you can
get a good service in the PHC, why go around?
I
The PHC doesn't have equipments for cesarians. We then go to a
private hospital without wasting time.
Gynecological Disorders
11 ■
4
131
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j
For gynecological disorders, 47 percent of the women said they would
prefer going to a private doctor in a nearby town or in Pune or
Bombay, whereas 37 percent would go to public health services rang
ing from their own PHC and its staff to the government hospital in
Pune. Sixteen percent said that they would use folk or traditional rem
edies or treat themselves.
f-
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My sister went to Kolhapur. In Lonand, Pune, and Bombay also you
can get these tests. The results are 99 percent right in Kolhapur, where
they use a TV [sonar-scanning device]. They don't perform these tests
in government hospitals.
Abortion Within Marriage
For nearly one-half of the sample (47 percent), the first choice of provider for an abortion within marriage was a qualified private doctor
in a nearby town. One-third would prefer their PHC, PHC staff (ANM
or nurse), or the taluka PHC. Eight percent said they would go to the
government hospital in Pune, and 6 percent would choose a private
hospital in Pune or Bombay. Two women (4 percent) preferred a local
abortionist. One woman said that she would never have an abortion,
and so the question of choosing a provider was not relevant to her.
132
Women's Perspectives on Quality in Rural Maharashtra
Manisha Gupte • Sunita Bandewar • Hemlata Pisal
Wezll go to a private doctor. There you can get what you want. In
the government hospitals they ask too many questions. In a private
hospital, you get the service immediately.
If you eat Anacin or malaria tablets, the pains start and you can drop
it [abort the fetus] at home.
She [an abortionist using a folk method] uses a root which is still
wet with its sap, which she puts inside you. After a few hours, the
bleeding starts and the root comes out with the whole thing.
Abortion Outside of Marriage
When asked what kind of provider they would choose if they were
seeking an abortion outside marriage, a sizable majority (61 percent)
said they would prefer a qualified private doctor in a town, whereas
22 percent would prefer going to a PHC, especially one at some dis
tance. Few (only 8 percent) would go to a government or private hos
pital in Pune or Bombay.
They ask for the husband's signature in the government hospital.
That's why it's difficult to go there.
It's the question of the girl's future. Who will answer all those ques
tions? In the government hospital, they take down your name and
address. Even if we have to sell our fields, we'll go to the private
doctor and then get her married off.
Views About Public Versus
Private Abortion Services
Using questions from a knowledge, attitude, and practice (KAP) sur
vey questionnaire on the MTP Act, we asked 67 women who had been
part of the focus groups about their preference regarding public or
private services for abortion care and problems of obtaining abortions
from both types of service. Forty-nine of the women who took part
in this section of the study had also participated in the quality of care
and choice-of-provider rank-ordering.
Forty-four women (66 percent) wanted abortions to be available
from the public sector, 6 (9 percent) preferred the private sector, and
17 (25 percent) wanted the service to be available in both sectors.
It [abortion] should be available in government services. How much
money they ask for in the private hospitals! The PHCs must become
MB
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133
more friendly to women. Private doctors will build tall houses with
our money. Do they care if the poor die? Medicines from the PHC
also go to the doctor's house for private practice. Just look at our
doctor—he didn't own a bicycle when he came. Now he has two
motorbikes and he's built a house in the taluka place.
Let it [an abortion] be available in both places. In the PHC, they keep
sending us back all the time. The pregnancy keeps advancing. If you
can pay, you'll get quick service in the private hospital. The rich can
go there. The poor will go to the government. Nobody cares if they
live or die.
As the following attests, public-sector providers also frequently
make access to abortion conditional upon a woman's accepting a long
term contraceptive method:
The doctor insisted that I should use a Copper-T, but my husband
was adamant that I shouldn't. I finally agreed to use pills, but the
doctor wouldn't trust me to take them regularly. The junior doc
tors asked their boss, and she said that I had to use the Copper-T
after all. Since I wanted to drop the thing [abort the pregnancy], I
then accepted the Copper-T, hoping that my husband would never
find out.
Asked whether the husband's signature was demanded when a
woman sought an abortion, 37 women (55 percent) replied in the af
firmative. Twenty-eight women (42 percent) said that private as well
as public services demanded the husband's signature. In fact, some
women reported that private doctors were more demanding because
they feared a legal threat from women's husbands. The demand for
the husband's signature was a source of great discontent among the
respondents.
Twenty-seven women said that only married women would use
abortion facilities if they were made available at the village level. An
other 27 said that all women, irrespective of their marital status, would
use village-level facilities.
Married women will use the benefit in the village because it will
save time and money. Even the others will go there secretly. They'll
pretend that their stomach is aching or something.
i
I
Once women trust the village-level service they will start going there.
Women from this village may go outside, but others can come here.
Sometimes a woman doesn't tell the mother-in-law. So she will have
to go somewhere outside.
134
Women b Feispectives on Quality in Rural Maharashtra
Manisha Gupte • Sunita Bandewar • Hemlata Pisal
Discussion
The findings indicate that women's major concerns about the quality
of general health care services reflect the needs of any rural popula
tion: the services must be nearby and easily accessible, and a doctor
should be available for handling emergencies at any time. The dis
tance and time involved in seeking services often determine how
much cost a household will incur. Most poor households cannot af
ford to spend money for women's medical services, and a woman's
access to health care is further reduced if the treatment is going to be
very costly—either in direct expenses or in lost wages or housework
lost due to her absence from the household.
Women expect a doctor to pay attention when he examines and
treats them. Many of the women we interviewed told us that their
doctor did not listen to their complaints, that instead he would inter
rupt them and try to get rid of them, especially if they were poor.
Women want doctors to treat them with more respect. Treatment by
a female physician was a consistently mentioned quality indicator,
irrespective of the type of treatment a woman was seeking. Respon
dents felt that they could discuss their symptoms more easily with a
woman doctor, and that they felt more secure in her presence than
with a male, especially when discussing sexual matters.
Most women consider empathy, concern, and counseling from
the doctor to be very important, especially in abortion care. Because
women are rarely attended by physicians during labor, however, those
attributes are not considered so important for delivery care. In nor
mal deliveries, women are supervised by other hospital or PHC staff,
about whom our respondents voiced many grievances. Women thus
consider courteous and respectful behavior from clinic or hospital staff
to be an important aspect of health care during deliveries and medi
cally terminated pregnancies.
Cleanliness is an important criterion for general health care and
deliveries. Some respondents complained that they had been made
to clean up the labor room when they accompanied a woman admit
ted for a delivery. They thought that hospitals and PHCs should be
adequately staffed with support staff to perform that function.
Women consider 24-hour service to be important for general
health care and during labor, but not for induced abortions, which
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can be scheduled during normal hours. When they have to stay at a
hospital overnight or for a few days, as in cases of serious illness or
during childbirth, they wish to have food facilities in the hospital
----- °-------------- ---------------------- -----premises. Because women who seek abortions generally return home
the same day, food and lodging facilities are not an important issue
for them.
In fact, women seeking induced abortions do not want to stay
overnight, mainly for social reasons and to maintain secrecy. In con
trast with their desire to have an easily accessible health service for
other types of health care, women in need of abortion services want
those services to be located at a discreet distance from their commu
nities—even though in the focus-group meetings respondents said
they wanted abortion services to be available in every PHC and as
nearby as possible. For most women in the six villages we surveyed,
abortion services were not available within a radius of 10 kilometers.
While the desire exists to have such services as close to home as
possible, social attitudes toward abortion make it extremely difficult
for a rural woman, especially if she is not married or living with her
husband, to obtain an abortion in her neighborhood clinic. The de
sire for secrecy and confidentiality overwhelms all other concerns
when single women seek abortions. Effective treatment, the availabil
ity of equipment and machinery, safety and reliability, the doctor's
attention and respect for the client—none of these criteria for quality
care has as high a priority in such situations. Women want a short
waiting period so that they are not seen sitting outside the doctor's
office. They want the procedure to require a single visit so that they
can terminate an unwanted pregnancy quickly and not have to re
turn to the same doctor. They want the physician who performs the
procedure to dispense any drugs they may require for follow-up care,
not as a convenience, but because they do not want to be seen acquir
ing medicine in the town or to arouse the pharmacist's suspicions.
Thus women who seek an abortion may overlook many of the con
siderations of good health care that they would normally regard as
important. For single women, the problem is magnified. Although
their first concern is confidentiality, women who undergo extramari
tal abortions want to receive empathy, concern, and counseling from
the doctor. Perhaps for that reason, having a female doctor is par
ticularly important to single women in such situations.
11
136
Women's Perspectives on Quality in Rural Maharashtra
Among married and cohabiting women, the major impediment
to obtaining an abortion is the doctor's insistence that the husband
approve the procedure by signing a permission form. This require
ment is more common at public health services than at private facili
ties, but many private doctors also resort to this defensive practice to
avoid having the husband create a scene or threaten to file a lawsuit
after an abortion has taken place. Being able to obtain an abortion
without the approval of their husbands has the highest priority for
married women who wish to terminate a pregnancy.
Single women who request an abortion also face impediments
from the health system. If they claim to be married, they may be re
quired to produce a husband's signature. If they admit that the preg
nancy was conceived outside marriage, they have to say that they were
raped or that they are wider
under physical or mental stress, the only other
conditions for induced abortion permitted by the MTP Act. For a single
woman to acknowledge her sexuality openly and, if pregnant, obtain
an abortion is to incur social censure. Single women who are sexually
active therefore are made to feel as though they are engaging in an
illegal activity, as well as ashamed and immoral. Their situation is made
worse by their limited access to good reproductive health care.
As we move from a consideration of how rural women in
Maharashtra perceive general health care to how they perceive the
provision of abortion services to women outside marriage, we find
that their perceived bargaining power is gradually reduced. Women
trade safety and good health care for confidentiality. Noticeable in
the women's narrations is that the word "abortion" does not appear
at all—it is taboo. One can thus begin to understand the plight of a
single woman seeking an abortion. Such a woman is a victim of
society's double standard of morality, and it is unfair that she must
risk her health to terminate an unwanted pregnancy.
Women choose providers pragmatically, using self-medication
and unqualified doctors for minor illnesses. In one of the narrations
quoted, the traveling practitioner is referred to as "Red Helmet," ob
viously because he wears a red helmet when he comes to a village on
his motorbike. Women are aware that he is not a doctor, but his serv
ices suffice because their health problems are not severe. In contrast,
women will turn to government services for chronic—that is, more
serious ailments, believing they will get reliable cures. For women
Manisha Gupte • Sunita Bandewar • Hemlata Pisal
-
137
with long-term diseases such as tuberculosis, itself an indicator of
l|p
poverty and malnutrition, private services are unaffordable. In emergencies, women will go to any provider who is immediately available; but after receiving first aid they will go to someone more competent, usually a private doctor, who is available day or night. They
’
8 E|| will do so even if it means traveling to the city, which may be as far
as 60 kilometers away.
For
ror care
care during
during ppregnancy, which usually involves simply laking iron and folic acid tablets and receiving TT shots, women prefer
Wi
< public health services. Most pregnant women in the area do not "reg■i| ister" with a doctor, and so the only services that are easily accessible
:|.
to them and free of charge are those of the PHC. Public health services
H
are also the first choice of women if they have to choose an institu
tional delivery, in spite of the fact that they do not regard themselves
& - as being well treated by
u/y the
uiv. staff.
ouuii. Their
11ten logic
logic is that
uicii unless
unless their
tneit labor
labor
J
is difficult, there is no need to spend money on a private doctor.
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sex-determination tests are available only in the private
■fc sector,Because
women choose to go there? as the first choice. Sonography is
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the more popular method, and it ’is often.......................................
followed by second-trimes
ter abortions. For gynecological ailments, women's first choice is a
private doctor, followed by the public health service. This preference
reflects poorly on the latter, which does not address women's health
needs beyond their need for maternity care and family planning.
The first choice of married women seeking abortions is the pri
vate sector, favored by slightly more than half of our respondents.
Because the government program asks for the husband's signature
and puts pressure on women to use contraception after obtaining an
abortion, some women consider the services hostile. For women seek
ing extramarital abortions, the clear-cut first choice is the private sec
tor because it is less rigorous in observing the provisions of the MTP
Act. Single women are made uneasy by being asked many questions,
having to tell lies, and knowing that their names are kept on record.
It is easier for them to go to a private doctor and have an abortion
quickly, without much fuss. Their primary concern is to guard the
family honor or, in the case of a mother with an unmarried pregnant
daughter, to ensure that the girl remains marriageable at any cost.
In conclusion, our findings suggest that women are critical of
the existing health services, including abortion services. They are upset
Women's Perspectives on Quality in Rural Maharashtra
13b
Manisha Gupte • Sunita Bandewai * llemlald 1
that doctors demand their husbands' approval before performing an
abortion and that government services pressure them to accept an
IUD after an abortion. They are also upset that private doctors take
advantage of their situation and charge them unreasonably high fees.
They resent having to pay for health services in the private sector
rk’.
because a PHC's staff is callous or its facilities are inadequate. Nev
ertheless, the women feel neither defeated nor cynical. They would
like their choices of care to be increased by having abortion services
located nearby, and even within their villages, thereby enhancing their
physical and economic access to safe abortion.
Acknowledgments
We are grateful to the Ford Foundation for funding the study reported here and
to the women who participated in the study as respondents and contact persons.
Note
I
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1
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B • ■.
1
The Medical Termination of Pregnancy (MTP) Act came into effect in April
1972. According to the Act, a pregnancy may be terminated by a registered
medical practitioner at a government-recognized venue: (1) as a health mea
sure when there is danger to the life or risk to the physical or mental health
of the woman (such as when a pregnancy results from the sex crime of
rape); (2) if pregnancy occurs as a result of failure of any device used by a
married woman or her husband; (3) on eugenic grounds where there is
substantial risk that the child, if born, would suffer from abnormalities and
disease.
References
Awasthi, Ramesh, Manisha Gupte, Roopashri Sinha, Sudhankar Morankar,
Sushama Sonak, and Savita Punyaliya. 1993. Strengthening Health Educa
tion Services: An Action Research Study. Bombay (Mumbai): Foundation for
Research in Community Health.
Bruce, Judith. 1990. "Fundamental elements of the quality of care: A simple
framework," Studies in Family Planning 21(2): 61-91.
Donabedian, Avedis. 1988. "The quality of care: How can it be assessed?" Jour
nal of the American Medical Association 260(12): 1743-1748.
Duggal, Ravi. 1995. "Our health costs little," in Our Lives, Our Health, ed. Malini
Karkal. New Delhi: Coordination Unit, World Conference on Women—
Beijing 1995.
Gupte, Manisha and Anita Borkar. 1987. Women's Work, Fertility and Access to
Health Care: A Socioeconomic Study of Two Villages in Pune District. Bombay
(Mumbai): Foundation for Research in Community Health.
j
•< r
I.E, .
1 S'
I'
9
1
II
■S’-
&
t
I
■
iI
h
Jesani, Amar and Aditi Iyer. 1993. "Women and abortion," Economic and Politi
cal Weekly 27(48): 2591-2594.
--------- . 1995. "Abortion: Who is responsible for our rights?" in Our Lives, Our
Health, ed. Malini Karkal New Delhi: Coordination Unit, World Confer
ence on Women—Beijing 1995.
Karkal, Malini. 1991. "Abortion laws and abortion situations in India," Issues in
Reproductive and Genetic Engineering 4(3): 223-230.
Nandraj, Sunil. 1994. "Beyond the law and the Lord: Quality of private health
care," Economic and Political Weekly 24(27): 1680-1685.
Parivar Seva Sanstha. 1994. Service Delivery System in Induced Abortion: A Report.
New Delhi: Parivar Seva Sanstha.
Phadke, Anant. 1994. The Private Medical Sector in India. Bombay (Mumbai): Foun
dation for Research in Community Health.
Roemer, M.I. and C. Montoya-Aguilar. 1988. Quality Assessment and Assurance
in Primary Health Care. Geneva: World Health Organization.
Simmons, Ruth, Marjorie A. Koblinsky, and James F. Phillips. 1986. "Client re
lations in South Asia: Programmatic and societal determinants," Studies in
Family Planning 17(6): 257-268.
United Nations (UN), Population Division, Department for Economic and So
cial Information and Policy Analysis. 1993. Abortion Policies: A Global Review, vol. 1. New York: UN.
U
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rs
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Part II.
Provider Perspectives
on the Quality of Care
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ui ivt’pioduclive Health Care in Gujarat
community, and clients—in discharging their duties or providing
services with a satisfactory quality of care. In spite of their consider
able experience, their views on the kinds of services, priorities, and
needs of the people are not taken into consideration by those who
design programs and assign their duties. This chapter discusses the
role and functions of ANMs as perceived mainly by the workers them
selves, but also by their clients, and suggests ways to improve the
health care delivery system.
-
Leela Visaria
(■
7
s
I
p
I ft
Data Sources
Four interrelated data sets, collected from surveys conducted under
the auspices of the Gujarat Institute of Development Research,
Ahmedabad, in rural areas of Gujarat State between 1989-90 and 1995,
form the basis of the profile of the ANMs presented here. They are
analyzed to develop a perspective on the nature of the ANMs' work,
the constraints they face, and their perceived priorities.
The first data source is a survey of a random sample of 9,600
rural households from 192 villages drawn from four districts of
Gujarat in 1989. The respondents were asked questions about their
contact with ANMs for antenatal care, curative care, and family plan
ning services; the quality of services provided by the health workers;
and the respondents' satisfaction with the services. The data indicate
the extent to which the health workers were accessible and respon
sive to the rural people.
The second source is a survey, also conducted in 1989, of 173
ANMs linked to the 192 villages. As a part of the study that produced
the first data source, we sought information from the health workers
about the problems they faced in delivering health services, their per
ceptions of the problems, and possible ways to overcome the diffi
culties. Data were also collected on the socioeconomic background
of the workers, their workload, the type and extent of logistic sup
port available to them, their knowledge and understanding of their
tasks, and the record-keeping system maintained by them.
On the basis of the records of acceptors maintained by the ANMs
working in the villages surveyed in 1989, in 1991 we selected 1,035
current acceptors of family planning methods. These were women
whose names had been recorded on the registers of ANMs as recipi
ents of family planning services during the two calendar years 1989
K
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and 1990. This additional survey was undertaken to ascertain the us
ers' satisfaction with the services and service providers; it incorpo
rated a detailed set of questions on the quality of care provided to
the users of various methods of family planning. The survey of users
was conducted in 22 villages from two of the four districts surveyed
earlier. Of the 1,035 women selected for interviews, only 692, or 67
percent, could be contacted. The remaining 33 percent could not be
interviewed because they were away from their village at the time of
the interviews, could not be traced, or their names were shown against
more than one family planning method. Only five women refused to
be interviewed (Visaria, Visaria, and Jain 1994).
The fourth data source is qualitative and is based on group dis
cussions with both ANMs and multipurpose male health workers in
1994
1994 and
and early
early 1995
1995 in
in some
some of
of the
the same
same villages
villages that
that had
had been
been surveyed in 1989 and 1991. Focus-group discussions and in-depth interviews were also conducted and tape recorded with acceptors of ster
ilization. They provide a perspective on the extent to which family
planning activities receive priority over the other health care activi
ties in the program. This qualitative information is partly anecdotal,
but it reflects the perceptions of women clients and health workers
and has helped us to interpret the quantitative data.
In profiling ANMs and their perspectives on the health and fam
ily planning program, I shall first examine the data on the sociode
mographic characteristics of the workers, the logistic support received
by them, their job responsibilities, and the support they received from
the community. Next I shall examine their interactions or contacts
with the clients and present data on the service users' perceptions of
the quality of care provided by the health workers. These various per
spectives are expected to broaden our understanding of the crucial
role of the health workers in service delivery in rural India.
ft
A Profile of the ANM
?
The task of contacting all ANMs in the 192 villages included in the
1989 study proved challenging.2 A significant number of the ANMs
could be contacted only after a second or even a third visit. The in
formation presented here pertains to 173 ANMs. We contacted them
at their subcenters or at their place of residence, rather than at the
primary health centers (PHCs) during their monthly meetings. The
;■
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146
Leela Visaria
Quality of Reproductive Health Care in Gujarat
TABLE 8.1
Demographic and socioeconomic profile of ANMs:
Four rural districts of Gujarat, 1989-90
Characteristic
Average,
all districts
Range
Age in years
Mean age
<25 (%)
25-34 (%)
35+ (%)
30
17
48
35
27-33
9-25
39-52
22-41
Marital status (%)
Never married
Currently married
Widowed, divorced, or separated
16
77
8
70-85
Years of service
Mean no.
<3 (%)
4-5 (%)
6-10 (%)
11+(%)
8
16
35
29
20
6-9
10-27
23-58
18-42
10-25
24
45
5
13
6
6
7-40
12-84
0-15
0-31
0-12
2-14
71
35
30
6
29
20
9
48-93
12^73
18-52
2-12
7-52
7-37
5-20
26
41
33
19-42
27-61
18-54
69
28
4
65-73
24-34
2-9
Caste or religion (%)
Upper Hindu castes
Lower Hindu castes
Scheduled castes
Scheduled tribes
Muslim
Christian or others
Residential pattern (%)
Living in subcenter village
Not provided government accommodation
Provided government accommodation and live in it
Provided government accommodation but do not live in it
Living outside subcenter village
Not provided government accommodation
Provided government accommodation
No. of hamlets or villages in jurisdiction (%)
Subcenter village only
2-3 villages
4+ villages
Mode of transport used to visit villages (%)
Walking
Public transport
Others
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8-19
5-11
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Note: Percentages may not add to 100 because of rounding.
ANM=auxiliary nurse-midwife.
rationale was that at the PHCs they were generally busy attending
meetings and were with other health staff and therefore may not have
had the time or may not have been willing to talk freely.
As shown in Table 8.1, four-fifths of the health workers were
above age 25. In two districts, however, nearly a quarter of the work-
I'■i
I
147
ers were under age 25 and presumably less experienced (data not
shown). Three-fourths were currently married, although every dis
trict had some unmarried health workers. If such women were not
"daughters of the village," ensuring their safety and security in the
subcenter villages appears to have been a serious problem. Overall,
more than four-fifths of the health workers had been working as
ANMs for four or more years.
The caste composition of the health workers was, by and large,
similar to the composition of the population in each district. In the
nontribal districts, most workers were drawn from the low Hindu
castes. In the tribal districts, nearly half of the ANMs were tribal or
belonged to scheduled or low Hindu castes. Interestingly, nearly a
quarter of the health workers belonged to the upper castes. The pros
pect of a regular and relatively attractive salary, as well as the need
to supplement the family income, seemed to have prompted highcaste Hindu women to enter this profession, which until recently was
pursued mainly by Christians or low-caste Hindus. All but one of
the health workers were fluent in Gujarati, although a few of them
had come from outside Gujarat. While interacting with people living
in rural areas who had little knowledge of any other Indian language,
these workers had acquired adequate knowledge of written and spo
ken Gujarati.
A major issue relating to the efficacy of health care delivery is
whether the ANM resides in the subcenter village and is easily acces
sible to the people. This is often said to be a necessary condition for
effective delivery of health services. Overall, more than 70 percent of
the ANMs in our sample resided in the subcenter villages to which
they had been assigned.3 An additional 13 percent of the ANMs lived
within three kilometers of their subcenters. Eleven of the 173 ANMs
lived more than 12 kilometers away from their subcenters. For those
ANMs who stayed in villages or towns removed from their subcenters
or in other villages under the subcenters' jurisdiction, their accessi
bility to the population appeared problematic. There were, however,
significant differences in living arrangements between districts.
Nearly 85 percent of the health workers in the tribal district of Bharuch
lived in the subcenter village, but only 48 percent of those in the other
tribal district of Panchmahals did so. The difference between the other
two districts was also striking. In Rajkot District, 41 of the 44 ANMs
Quality ul Reproductive Health Care in Gujarat
Leela Visaria
i-iy
■
interviewed lived in the subcenter village, whereas in Kheda District
more than a third of the ANMs lived outside their area of jurisdic
tion and commuted to their subcenter area.
Some of the health workers who were provided accommodation
chose not to stay there and instead either rented houses within the
village or stayed in their own homes, if they owned a house in the
subcenter village. Among the reported reasons for not staying in the
subcenter building were its dilapidated condition and its location out
side the village proper. The nonoccupancy contributed to a further
deterioration of the buildings in most cases; some of them were even
vandalized. Given the paucity of maintenance funds, these buildings
cannot easily be made usable.
In the villages that did not have a subcenter building, the health
workers had to find a dwelling either within the subcenter village or
elsewhere. In Rajkot District most of the subcenters did not have their
own building; nevertheless, nearly 73 percent of the health workers
were reported to be staying in the subcenter villages, either renting
accommodations or living in their own houses. (It is not clear whether
the health workers in Rajkot were recruited locally or an effort was
made to place them in their places of origin.) Otherwise, the willing
ness of the health workers to find accommodation in the subcenter
villages and to live there is commendable. The situation in
Panchmahals and Kheda Districts, with a high percentage of the health
workers living outside the subcenter villages, posed a problem for
residents, who had limited access to the workers.
Throughout the Family Welfare Programme, health workers are
assigned the task of providing services to a population of about 5,000
in nontribal areas and about 3,000 in the tribal areas. In areas or dis
tricts where the average size of villages is small, this norm often im
plies that the health workers must provide services to more than one
village. In large villages, such as those in Kheda District, more than
one health worker is assigned to a single village. Among the health
workers we surveyed, each was assigned an average of 2.8 villages,
but 26 percent of the ANMs had to cover only the village in which
their subcenter was located. Most of the other villages were near the
subcenter village and situated at an average distance of 3.5 kilome
ters from the subcenter.
Among the four districts, variations in village size led to differ
ences in the number of villages to be covered by the ANMs and in
. fc'
‘ K'
• I--'
■
r'I-
I
r'
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*
F
I-
ll |
■ fe
■
I
k.
TABLE 8.2
Logistic support received by ANMs: Four rural districts of Gujarat, 1989-90
Average,
all districts
Range
Physical facilities (% of subcenters)
Subcenter’s own building
Rented by or donated to subcenter
None—functioning from ANM s residence
58
30
12
33-81
10-46
3-37
Equipment in working condition (% of subcenters)
Examination table
Blood-pressure instrument
Stethoscope
Weighing machine for adults
Delivery kit
Delivery pack
60
34
38
58
81
33
50-75
22-52
27-65
38-90
65-92
12-50
Basic supplies in stock (% of subcenters)
Basic curative medicines
Iron and folic acid tablets
ORS packets
Cotton
Kerosene, fuel oil
Chemicals for hemoglobin test
57
95
82
83
36
52
42-82
88-100
58-98
70-91
18-65
10-82
Type of support
ANM=auxiliary nurse-midwife; ORS=oral rehydration solution.
the distance to be traveled to reach them. Given the relatively large
size of villages in Kheda District, about 41 percent of the health work
ers there served only their subcenter village; in the other districts,
the corresponding figure was only about 20 to 25 percent. The tribal
villages tend to have small populations; therefore, in spite of being
assigned smaller populations, almost four-fifths of the health work
ers were required to provide services to two or more villages. The
somewhat difficult terrain, inclement weather, and inconvenient pub
lic transportation facilities posed problems of effective coverage. A
majority of the health workers reported that they generally walked
to the villages under their jurisdiction, and only about a quarter of
them used public transportation.
Logistic Support Received by
Health Workers
I’
Br
1 1If
To assess the availability of support services to the health workers,
we asked them questions about the physical facilities and equipment
they had been provided. As Table 8.2 indicates, nearly nine-tenths of
the workers functioned from buildings provided to them. An excep
tion was in Rajkot District, where more than a third of the health work-
H
11
150
Leela Visa ria
Quality of Reproductive Health Care in Gujarat^.
ers operated from their own homes. Typically, a health worker is pro
vided with certain equipment and supplies; she also requires some
privacy when meeting with clients. Having to function from her own
home poses serious problems for her in taking care of the equipment
and providing adequate and private access to clientele.
When we asked the health workers whether their equipment was
in usable condition, a majority reported that vaccine carriers, stoves,
test tubes, and similar items were generally in working order. How
ever, we observed that in most of the subcenters, those items were ly
ing idle or unused, often in the cartons in which they had been deliv
ered. The immunization program, as it is being implemented, does not
require the ANM to be equipped with a vaccine carrier or related equip
ment. Lady health visitors (LHVs), assisted by male health workers, bring
the vials of vaccines from the PHCs directly to the ANMs in the villages.
With the exception of Bharuch District, however, fewer than 30
percent of the ANMs reported that the equipment they used on a regu
lar basis to provide antenatal care was in working order. That equip
ment included blood-pressure instruments, stethoscopes, and weigh
ing machines for adults. The family planning program has provided
basic equipment to most subcenters but has not been able to provide
small maintenance budgets or regular supplies such as chemicals or
kerosene, which are needed to operate some of the equipment. We
found, for example, that even if a hemoglobin meter was in working
condition, the lack of basic chemicals prevented health workers from
using the equipment to check for anemia in pregnant women. Con
sequently, antenatal care consisted of giving pregnant women iron
and folic acid tablets, which were available in adequate quantities
most of the time, and providing them with verbal reassurance. Most
of the health workers also reported having adequate stocks of oral
rehydration solution, intended for treating diarrhea among infants
and children, although the workers indicated that they rarely used
them.4 However, 43 percent of the ANMs said they were not provided
adequate quantities of basic curative medicines. The situation with
regard to the availability of drugs was much better in Rajkot District
than in the other three districts.
The shortage of basic medicines was due in part to villagers' de
mands for remedies for minor ailments, such as stomachache and di
arrhea. The health workers could not easily deny them the medicines
for fear of losing support for the Family Welfare Programme. Some
I*■
151
r '•
TABLE 8.3
Indicators of the availability of IUDs and oral contraceptives from ANMs:
Four rural districts of Gujarat, 1989-90
F
Method and indicator
•
I
- |
B.
: SiS'-
I
I
•
B Bl
I■pi■
Average,
all districts
Range
IUDs
ANMs reporting having been trained in IUD insertion (%)
ANMs reporting the ability to insert IUD themselves (%)
Average no. of IUD insertions in the year preceding survey
ANMs reporting having a stock of IUDs (%)
95
87
25
94
92-100
64-98
16-38
87-100
OPs
ANMs having an OP checklist and able to produce it (%)
ANMs having an OP checklist but not able to produce it (%)
ANMs not having an OP checklist (%)
54
41
5
32-100
34-67
3-15
ANMs reporting that pills could be given to all women
who want to delay pregnancy (%)
37
5-72
ANMs reporting specified contraindications for pills (%)
Woman's age >35 years
Woman is pregnant
Woman has high blood pressure
Woman suffers from any disease
17
14
57
19
10-30
4-32
44-72
6-35
ANM=auxiliary nurse-midwife; IUD=intrauterine device; OP=oral pill.
' ■i
F
workers even reported to us that they used their own money to buy
basic drugs for the villagers.
St'.- :
■ te
L
i. ?'
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I ir-
I
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- L'
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IR
1l 1b
08(54
Family Planning Activities
It is well known that health workers spend a major portion of their
time on activities associated with meeting the family planning tar
gets assigned to them. The health workers are trained in intrauterine
device (IUD) insertion and in advising women about the advantages
and risks associated with oral contraceptives. Practically all the ANMs
surveyed by us reported that they had received training in IUD in
sertions; a large majority of them said they could actually insert IUDs
without assistance from the LHVs (Table 8.3). Only in Kheda District
had some of the recent recruits not received the necessary training.
The average number of IUDs that the ANMs reported having inserted
in the year prior to the survey, if accurate, was quite impressive, rang
ing from a low of 16 in Panchmahals District to a high of 38 in Rajkot.
We subsequently learned that the average of 25 IUD insertions reported
by the ANMs corresponded to the yearly targets assigned to them.5
Until recently, the Indian government did not make oral contra
ceptives available on a large scale. Consequently the targets for them
Quality ul Reproductive ileal th Care in Gujarat
TABLE 8.4
Average number of family planning clients per ANM reported for the year
SUrVe^’
rnelhocl accepted: Four rural districts of Gujarat,
Method
Condom
~
Average,
all districts
Range
37
IUD
21-59
26
16-39
Female sterilization
Pills
12
12
Vasectomy
0
All methods
6-1
87
56-120
6-20
ANM=auxiliary nurse-midwife; IUD=intrauterine device.
have not been as high as those for other methods, such as IUDs and
condoms. Almost all the health workers we surveyed reported that
they prescribed the pills only after examining prospective users. The
ANMs were provided with a checklist of conditions under which pills
should or should not be prescribed. In Bharuch and Fanchmahals Dis
tricts, we attempted to verify whether health workers had the check
list with them and could produce it. In Fanchmahals District, only about
a third of them could show it to us. When asked about the specific con
ditions when oral pills should not be given, nearly 20 percent gave
vague responses such as when a woman suffers from any disease." A
sizable proportion of the ANMs reported that pills were contraindi________
cated when a woman suffered from hypertension. While the checklist
d_________ r or- i
,,
...
.
..
prescribed that women above the age of 35 should not take oral pills,
only 17 percent reported that factor as contraindicative for oral pills.
Table 8.4 indicates an impressive level of achievement by the
health workers in fulfilling their method-specific family planning tarrrz-Hc'
.
gets. Having to persuade ________
more.1 than
80 new <couples every year to
adopt a family planning method is no small task. However, elsewhere
it has been demonstrated that the fulfillment of targets with regard
to reversible methods is largely exaggerated in Gujarat (Visaria,
Visaria, and Jain 1994). The monitoring system is such that if the health
workers do not report an acceptable level of performance, they are
reprimanded at their monthly meetings and threatened with the with
holding of an annual salary increase or even a transfer to a new loca
tion (which is usually seen as a punishment). They all get the mes
sage and learn to report "correct" numbers.
I
Leela Visa ria
Another facet of the targets for the health workers relates to the
government s system of compensating for poorly performing PHCs
by assigning higher targets to the better performing PHCs within the
fl
same districts. A similar process of compensation with better perform
ing districts presumably occurs at the state level. The interdistrict
variations can be quite large, as is evident in Table 8.4. During our
discussions with health workers, we learned that the health workers
of the better performing PHCs in Bharuch District resented having
been
given 20
percent higher targets because other PHCs in their disLfe
----- targets
Decaus
iy
trict were not up to the mark. This issue is’ n°t a serious one in real
ity, except that the incremental targets are also method-specific and
imply that the ANMs hav.
; g|
have to persuade a few additional couples to
■ElW-____ . .. .1.
_
f
accept sterilization. Compared with other methods, sterilization
,'
records are difficult to forge. It is our observation that official figures
■i |fc:
on sterilization acceptors correspond closely to the actual numbers
E? ■
of acceptors of this method (see Visaria, Visaria, and Jain 1994). As
far
as the other methods are concerned, it is an open secret that their
.i
B... fulfillment exists only on paper.
>.
•
I
4I
I
■
1
if ■
I K;
1
1 .
t
t k
I
.
I
Prioritization of Activities
In Bharuch and Fanchmahals, we asked health workers to rank their
mam tasks, or activities, according to their own priorities and the prionties of their supervisors. (This question was not posed in the other
two districts.) The activities listed were maternal health, immuniza
tion of children, family planning, and maintenance of registers.
Almost none of the health workers thought that the maintenance of
registers was an activity that could be compared with the other three
and
_ ___
and thprpforp
therefore mnct
most rlirl
did not rank .•».
it. tIn
response to several questions
about record-keeping, a majority of them stated that the task was
tedious and took up a lot of their time, but that they managed to maintam uP-to-date records with the help of the LHVs, their supervisors
In fact, the major function of the supervisors is to assist health work
ers in preparing information sheets for the monthly meetings at the
PHCs.
The health workers ranked their supervisors' priorities on the
basis of the emphasis placed on various activities at the monthly meet
ings attended by the ANMs at the PHCs. On the one hand, according
u
H
154
TABLE 8.5
ANMs’ ranking of their tasks according to the priorities of their supervisors
and their own priorities: Bharuch and Panchmahals Districts, Gujarat, 1989-90
Percentage of ANMs ascribing specified rank
(both districts)
Source of priority and task
Leela Visaria
Quality of Reproductive Health Care in Gujarat
1st rank
2nd rank
■
■ T
’ I-
V fe
1W
TABLE 8.6
Contact of respondent households with health workers
and utilization of health services: Four rural districts of Gujarat, 1989-90
Percentage of women
reporting contact
3rd rank
Type of contact
Supervisors
Maternal health
Immunization
Family planning
15
20
69
27
56
17
58
24
14
ANMs
Maternal health
Immunization
Family planning
76
22
7
20
63
15
4
16
78
Households reporting visit in six months
preceding survey, by type of worker
ANM
Male health worker
LHV
(No. of households)
1
Note: Percentages may not add to 100 because of rounding.
ANM=auxiliary nurse-midwife.
to the health workers, 69 percent of the supervisors (80 percent in
Bharuch District and 57 percent in Panchmahals District) placed top
priority on family planning work, and only 15 percent of them as
signed first rank to maternal health (Table 8.5). On the other hand, 76
percent of the ANMs themselves felt that maternal health should re
ceive top priority, and only 7 percent felt that family planning should
receive top priority. Many of them even stated that if mothers and
children received good health care, there would be no need to em
phasize family planning because women would seek family planning
services on their own.
Health workers' perspectives on their supervisors, their views
about their own responsibilities, and the quality of care provided to
the service users can be better understood in the context of the views
and opinions of the service users themselves. The next two sections
address those issues by reviewing the responses of clients.
Clients' Contacts with Health Workers
and Subcenters
I
4 r
II
Women reporting contact with ANM during
current8 or last pregnancy
Last pregnancy registered with ANM
Current pregnancy registered with ANM
Tetanus toxoid injections received during last pregnancy
Tetanus toxoid injections received during current pregnancy
Hemoglobin checked during last pregnancy
Iron and folic acid tablets received during last pregnancy
Assistance by ANM during delivery at home
(No. of women)
wI
155
Average,
all districts
Range
73
72
2
(9,471)
(2,329-2,399)
48
38
45
13
31
42
5
29-66
26-48
25- 60
10-16
20-47
26-58
1-12
(8,461)
(1,823-2,449)
61-93
61-85
0-4
ANM=auxiliary nurse-midwife; LHV=lady health visitor.
8 At the time of the survey.
a
I*
Jlr\
■
■ I
- .
In the survey of village women conducted in the four districts of
Gujarat in 1989, we asked respondents whether workers had vis
ited them to offer various services. Their responses were affected
by their ability and willingness to recall events that had occurred
up to six months preceding the survey. Even so, the responses indi
cate the extent of contact between the health workers and the rural
I:-
I
I
•r
■
/
population and the availability of various health services to rural
women.
Table 8.6 summarizes the responses to questions about whether
the health functionaries had offered respondents antenatal and natal
care. Overall, nearly three-fourths of the respondent women indicated
that they had been visited by a FHW or a male health worker during
the six months prior to the survey. Health workers making regular
visits to the villages have become a familiar sight in Gujarat, and most
respondents said they were able to recognize the ANM.6 We found
some interdistrict variations in the reported visits of the ANMs, how
ever. In the tribal district of Bharuch, where a relatively high propor
tion of respondents (55 percent) reported using contraception, 61 per
cent said they had been recently visited by a female or male worker.
In Panchmahals District (which has a contraceptive use rate of 36 per
cent), despite the dispersion of villages over a large area, the scat
tered housing pattern within villages, and the fact that many of the
surveyed villages did not have a health worker living within their
borders, nearly 70 percent of the respondent women reported a re-
loo
Leeia Visaria
Quality of Reproductive Health Care in Gujarat
cent visit by a health worker. We had expected the respondents from
that district to report low contact with the health staff. It is quite likely,
however, that the lower acceptance of family planning in Panchmahals
has led health staff to make more frequent visits there. Although direct evidence is not available on this issue, other data presented in
Table 8.6 corroborate this hypothesis.
In spite of regular visits to the villages by the ANMs, fewer than
30 percent of the women of Panchmahals District reported having
received tetanus toxoid (TT) injections or iron and folic acid tablets,
while the corresponding figure was more than 40 percent in the other
three districts (data not shown). Evidently the visits of the health
workers in Panchmahals were not related to the provision of antena
tal care. It is probable that the ANMs sought to recruit family plan
ning "cases," even though they believed that maternal health should
receive top priority in the list of their activities.
For natal care, most women in rural areas seek the help of a lo
cal dai (traditional birth attendant) if they anticipate no complications
during delivery, or go to a private doctor or nursing home or to a
government hospital in a nearby town if they or the dai anticipate
complications. A majority of the respondent women in the four
Gujarat districts were not even aware that their ANM could be con
tacted to assist in deliveries. In Rajkot District, 12 percent of respon
dents who had delivered their children at home had called upon an
ANM for assistance at the time of delivery, but in the other three dis
tricts fewer than 3 percent of the women reporting a birth said they
had received assistance from an ANM during delivery. Many respon
dents felt that a nurse who did not stay in the village could not be
called or put to inconvenience and would not come even if called.
A high proportion of ANMs, when asked about the number of
deliveries they had assisted, reported having a much greater role in
natal care than was suggested by the respondents. During our focusgroup discussions, however, the health workers mentioned concerns
about their personal safety when called at night, the antagonism of
some villagers or communities directed toward them, and the risks
involved when called to attend a complicated delivery. The health
workers preferred not to attend deliveries and believed that the local
dais were best suited for the task. Perhaps they mentioned assisting
at deliveries because it was one of the tasks assigned to them, and
mentioning it improved their service record.
I-'
sKII ■
I
I
■’ r
I
I:-'
I
■ B
■ I
*
J'
i
: £
Quality of Care Provided to
Women Sterilization Acceptors
A major responsibility of health workers is to motivate couples to
adopt a family planning method and provide the necessary services,
which range from taking women to the sterilization camps at PHCs
or government hospitals to bringing them back and providing fol
low-up care. For users of reversible methods, the health workers are
expected to provide supplies (condoms and oral pills) and services
(e.g., IUD insertions).
Our information on the dimensions of quality of care provided
to sterilized women is derived from the 1989 survey of women in the
four Gujarat districts and from the follow-up survey of acceptors in
the two tribal districts of Bharuch and Panchmahals during 1991. The
latter group had accepted family planning methods in the calendar
years 1989 and 1990 and were reported to be using either the accepted
methods or some other method at the time of the survey. Some ques
tions were similar in the two surveys, but the later survey included
additional questions. Table 8.7 presents data based on the four-dis
trict survey, and Table 8.8 presents data from the follow-up survey
in two tribal districts.
As shown in Table 8.7, only 10 percent of sterilized women from
the four districts reported having been informed about other family
planning methods by the health workers. In tribal districts this per
centage was even lower, at 3 percent (data not shown). At the time of
sterilization, almost all women were given a IT injection to minimize
the risk of infection. About half of all sterilized women were steril
ized at the PHC or at the weekly camps organized by the PHCs. An
additional 45 percent were sterilized at government hospitals.
Interestingly, 41 percent of the sterilized women said they had
been self-motivated to adopt the method, and only 29 percent had
been motivated by a FHW. The role of nonhealth staff, such as school
teachers, village revenue functionaries, and village heads, in moti
vating women to accept sterilization was substantial, accounting for
16 percent of all sterilization cases. The roles of health and nonhealth
personnel varied according to the district.
Although proper follow-up is an essential component of the qual
ity of service, overall only about one-half of the women reported a
follow-up visit by the health worker. Admittedly, our sample includes
H
158
Leela Visa ria
Quality of Reproductive Health Care in Gujarat^
TABLE 8.7
Contact of sterilized women with health workers and services received:
Four rural districts of Gujarat, 1989-90
Percentage of sterilized
women reporting
contact or service
Type of contact or service
Average,
all districts
Range
Informed about other family planning methods by health workers
10
3-18
Received TT injection prior to sterilization
96
94-98
Surgery performed at
PHC or PHC camp
Government hospital
Private hospital or other
49
45
6
37-60
35-60
4-10
Motivated to accept sterilization by
Self
Female health worker
Other health worker (male health worker, PHC doctor, or other)
Other (teacher or revenue official)
41
29
14
16
36-50
20-39
12- 18
13- 21
41
60
55
49
49
(4,084)
36-57
50-80
35-74
40-64
42-67
(707-1,247)
Received follow-up care from ANM according to
who motivated respondent to accept sterilization
Self
ANM
Other health worker (male health worker, PHC doctor, or other)
Other (teacher or revenue official)
All motivators
(No. of sterilized women)
fe
:l7
j
ANM=auxiliary nurse-midwife; PHC=primary health center; TT=tetanus toxoid.
some older women who must have been sterilized several years prior
to the interview and therefore may have had problems of recall. Nev
ertheless, one of the major complaints we heard against the ANMs
was that they were interested primarily in recruiting sterilization ac
ceptors. According to many respondents, once a woman was steril
ized, the ANM rarely visited her after the first checkup.
When we examined the incidence of follow-up care according
to who had motivated the women to accept sterilization, it became
evident that proportionately fewer women who had been either self
motivated or motivated by nonhealth staff received follow-up care
than did women who had been motivated by health workers; the dif
ference was statistically significant. During the in-depth interviews
and in focus-group discussions with contraceptive users, it was sug
gested that health workers were denying follow-up services to women
who had not been motivated by them. Many of our informants re
ported that although health workers worked hard to motivate- their
I
159
"cases" so as to meet their annual sterilization targets, other local func
tionaries—talati (revenue officials), school teachers, or anganwadi
workers (women in charge of the centers under the Integrated Child
Development Scheme)—who were not connected with the health sec
tor were able to "snatch away the cases" and take credit for motivat
ing them. The nonhealth functionaries, they asserted, were able to do
so by promising the acceptors a higher incentive in cash or kind. The
health workers then retaliated by refusing to provide follow-up ser
vices to those acceptors. Some of the health workers themselves con
firmed this during a group discussion. Women who had been denied
follow-up services often regretted having been lured by the prom
ises of nonhealth staff, which were almost never fulfilled.
On the basis of acceptor records maintained by the FHWs for
. calendar years 1989 and 1990, we attempted in early 1991 to trace the
acceptors of various methods in 22 villages of the districts of Bharuch
and Panchmahals. Of the 259 sterilized women we contacted, almost
all (254) confirmed that they had indeed been sterilized in the previ
ous two years. As shown in Table 8.8, their average age at the time of
sterilization was 26 years. They had an average of nearly four chil
dren at the time they were sterilized, ranging from 3.4 children in
Bharuch to 3.9 children in Panchmahals.
When asked whether they had used any other method of fam
ily-size limitation before accepting a permanent method, 92 percent
of the women reported that sterilization was the first and only method
they had used. Only 12 percent of the women (5 percent in
Panchmahals and 20 percent in Bharuch) had been offered a choice
of other contraceptive methods. The literature on quality of care may
emphasize choice as an important dimension of quality, but women
in rural areas of India appear to enjoy little choice in real life. It ap
pears that women may even reject choice on their own because steril
ization, in one stroke, takes care of their contraceptive needs. In this
survey, 41 percent of sterilized women also reportedly had been self
motivated. About the same proportion (43 percent) of women had
been motivated by health workers (including male health workers,
who also had to meet family planning targets), and the rest had been
motivated by the other village functionaries.
At the sterilization camp or clinic, care provided to the women
consists of a health checkup, a TT injection, and the operative proce
dure performed under general anesthesia. As shown in Table 8.9, how-
j
I
160
Leela Visaria
Quality of Reproductive Health Care in Gujarat
TABLE8.9
Care received at the time of sterilization by women sterilized in 1989-90:
TABLE 8.8
Profile of women sterilized during 1989-90: Bharuch and Panchmahals
Districts, Gujarat (based on 1991 retrospective survey)
Characteristic
Average,
both districts
Mean age at the time of sterilization (years)
Mean number of children
Percentage for whom sterilization was the only method of family planning used
Percentage offered a choice of other methods (excluding self-motivated)
Percentage motivated to accept sterilization by
Self
ANM
Male health worker
Teacher, revenue official, or other village functionary
(No. of sterilized women)
26
3.7
92
12
41
34
9
16
(254)
ANM=auxiliary nurse-midwife.
ever, about 59 percent of the women reported suffering pain or dis
comfort during the procedure. It is quite likely that in those cases the
effect of anesthesia had worn off before the procedure was completed.
Only about a quarter of the women reported having been given snacks
and coffee after the operation. The provision of this prescribed post
operative stimulant was reported to be much lower in Bharuch (15
percent) than in Panchmahals (41 percent). The reasons for such large
differences between districts in the provision of snacks are unclear be
cause the money for such services is earmarked on a uniform basis.
Women who agree to accept sterilization are "highly prized" hu
man beings until the time they are sterilized. The health workers ac
company their cases to the place of sterilization, partly out of fear
that they may lose them to other functionaries, or that the women
themselves may change their minds and decide not to undergo ster
ilization. By accompanying the women, the health workers are able
to hold on to their cases. The functionaries who take their clients to
the venue of sterilization also undertake the responsibility of bring
ing them back to their homes.
As shown in Table 8.9, nearly one-half of the women we sur
veyed reported that they had traveled in state transport buses to the
venue of sterilization. In about one-fifth of the cases, a PHC vehicle
was provided. After the sterilization, nearly three-fourths of the
women were brought back in the PHC vehicle, and for one-fifth of
the women a private vehicle was hired.
Bharuch and Panchmahals Districts, Gujarat
(based on 1991 retrospective survey)
Average,
both districts (%)
L
: t.
I
I
Place of sterilization and care received
Place of sterilization
PHC camp
Government hospital
PHC
Private hospital
Care received during sterilization
Health check up
TT injection
General anesthesia
Pain suffered during operation
Snacks after sterilization
i..
Accompanied by
ANM
Anganwadi worker
Teacher or other functionary
Male health worker
Dai
Mode of transport
State vehicle
PHC vehicle
Private vehicle
Walking
___________________________
61
24
8
8
89
100
97
59
28
While being taken
to sterilization site
62
12
12
8
6
After
sterilization
57
14
14
10
5
49
21
20
10
5
74
20
1
Note: Percentages may not add to 100 because of rounding
ANM=auxiliary nurse-midwife; PHC=primary health center; TT=tetanus toxoid
j-
•;
The PHC jeeps are used extensively to transport sterilized women
to their homes, even if only one woman has to be transported over
some distance. The transportation provided to women is one service
that compensates for several shortcomings of the sterilization pro
cess, including the occasional highhanded behavior of the health func
tionaries. Women rarely report dissatisfaction with the quality of ser
vices provided to them. In fact, many express a sense of gratitude
because, in spite of the unpaved road, a jeep is sent even at night to
drop a sterilized woman right at her doorstep.
After the sterilization operation, 84 percent of the women we sur
veyed reported being visited by a health worker for a checkup (Table
8.10). The women who underwent a laparoscopy were generally vis
ited at home for removal of the bandage. Tubectomy patients were
apparently advised to consult the doctor postoperatively and were
therefore instructed to visit the PHC. About a quarter of the steril-
162
Quality of Reproductive Health Care in Gujarat '
? ft?
|
TABLE 8.10
Poststerilization follow-up care received by women and complications
experienced: Bharuch and Panchmahals Districts, Gujarat, 1989-90
(based on 1991 retrospective survey)
Follow-up care and complications
Average,
both districts (%)
Visited and checked up by health worker
84
Instructed to return for checkup
55
Place suggested for checkup (among those instructed to return)
PHC
ANM's residence
Subcenter
Other
Experienced complications after sterilization
Type of complication (among those reporting complications)
Weakness
Backache
Bleeding
White discharge
Other
Experienced continuing complications
Satisfied with sterilization
1
.■I
L ■
|P
84
7
3
6
26
22
11
8
5
55
68
93
ANM=auxiliary nurse-midwife; PHC=primary health center.
ized women complained of heavy bleeding, backache, weakness, or
other discomforts after the operation. Those women felt that their com
plaints were generally ignored or brushed aside by the health work
ers. On the other hand, health workers felt that clients' complaints
were often vague and in most cases probably due to the poor health
of the women, rather than to the surgery itself. Two-thirds of the ster
ilized women continued to experience discomfort up to the time of
the survey. Responding to questions about their health status, they
typically reported that their body had never regained full vitality af
ter the operation. Nevertheless, 93 percent of the women did not re
gret having undergone sterilization and would even recommend it
to others. A majority of those who regretted the sterilization had ex
perienced the loss of a child since the procedure.
Users of Temporary Methods
For the users of temporary methods, our survey had an extensive set
of questions to determine the quality of care received by them. How
ever, of the 530 women listed as current acceptors of IUDs, condoms,
and orals whom we interviewed in 1991, only 73 women (14 percent)
T
!
II
r
f
f
i
h
i
Leela Visaria
163
reported that they were currently using a temporary method. An ad
ditional 39 women (7 percent) indicated that although they were not
using a temporary method at the time of the survey, they had used it
in the recent past. The pressure to meet method-specific targets
prompts many health workers to include among the acceptors some
individuals who are not eligible because of their marital or pregnancy
status, to report the same person as having accepted two methods, or
to list fictitious names of acceptors who cannot be traced. We found
that many of the 86 percent of current nonusers who had been listed
as current acceptors were fictitious or duplicated names or
nontraceable or noneligible acceptors. We sought to ascertain the rea
sons for discontinuing use by questioning actual acceptors whom we
could contact and learned that such factors as a current or recent preg
nancy, desire for more children, and husband's opposition to contra
ceptive use were the main reasons (see Visaria, Visaria, and Jain 1994).
Among the listed acceptors of the various reversible methods, more
than 50 percent were classified as condom acceptors; the figures for ac
ceptance of this method corresponded closely with the mandated
method-specific targets. However, actual users of this male method
formed an insignificant proportion of the acceptors (12 couples, or
4.5 percent of the 265 acceptors of condoms). Clearly, health workers
distribute large quantities of condoms (or distribute them on paper),
and distribution is equated to use with some numerical adjustment. The
data suggest an enormous waste of scarce resources.
About a third (180) of the 530 reported current acceptors of re
versible methods were classified as IUD acceptors. However, at the
time of the January 1991 survey only 52 women (29 percent) reported
themselves as current users of IUDs and an additional 14 (8 percent)
indicated that they had used an IUD in the recent past but discontin
ued its use after some time. The current users of IUDs accounted for
more than 70 percent of the total of 73 current users of the three tem
porary methods of the program. Among the temporary methods of
fered by the Family Welfare Programme, the IUD appears to be much
more acceptable than any other method. Oral pills have played an
insignificant role in the program, possibly because a small target has
been established for them.
Of the 66 confirmed ever-users of IUDs, 62 percent had the de
vice inserted at a PHC or government hospital and about one-fourth
went to a private clinic for the insertion (Table 8.11). Only about 15
11
164
Quality of Reproductive Health Care in Gujarat
Leela Visaria
TABLE 8.11
Quality of care provided to ever-users of IUDs, as r:
r_
reported
by users:
Bharuch and Panchmahals Districts, Gujarat, 1989-90
(based on 1991 retrospective survey)
I
Average,
both districts (%)
Circumstance
Place where IUD was inserted
PHC
Government hospital
Private clinic
Subcenter
Acceptors informed about other methods
Reason(s) for preferring IUD
Other methods not convenient
Found it convenient in the past
Did not know about other methods
Other
Received a checkup before IUD insertion
Care taken by provider before insertion
Washed hands
Put on gloves
Boiled instruments
Don't know
Experienced pain during insertion
s
very observant.) A quarter of the women experienced pain during
the insertion, and nearly all of these women complained to the pro
vider. In three-quarters of such cases, some painkiller was dispensed.
About two-thirds of the women reported a follow-up visit by a health
worker at home. Very few women (2 percent) regretted having accepted
the IUD.
ft;
Conclusion
'I
~~
Person who inserted IUD
“Nurse”
Doctor
I
“
Among those who experienced pain
Complained about pain to provider
Was given painkillers
Received a follow-up visit at home
Did not regret the IUD insertion
(No. of ever-users of IUDs)
49
13
24
15
86
14
12
55
21
14
10
49
41
41
4
14
25
I
93
77
67
98
(66)
IUD=intrauterine device; PHC=primary health center.
=*i
percent were provided the device at their subcenter, probably because
of the lack of adequate facilities at the subcenters. A "nurse" attached
to the PHC or hospital provided the service in 86 percent of the cases.
Only 12 percent of the IUD acceptors received any information about
other methods of family planning. They accepted an IUD because they
felt that other reversible methods might not be convenient, they did
not know about the other methods, or their past experience with an
IUD had been satisfactory and therefore they wanted to use it again.
Nearly one-half of the IUD users reported receiving a checkup
before the device was inserted. A little over 40 percent of the users
indicated that the provider washed his or her hands and wore gloves
before inserting the device. (It is possible that others may not have been
!■
!
-
The data presented above offer several important lessons for the Fam
ily Welfare Programme. When our studies were conducted in rural
areas of Gujarat during 1989-91, the concept of reproductive health
was not as well crystallized as it has become since the United Na
tions Conference on Population and Development, held in Cairo in
1994. As a signatory to the conference's Programme of Action, India
needs to review its Family Welfare Programme in the context of the
commitments made in Cairo to promote reproductive health among
women. The concerns voiced by the health workers in Gujarat in 1989
are, in a sense, echoed in the Cairo document. If we are able to pro
vide good health care to women before, during, and after childbirth,
and to instill confidence in them that their children will receive good
health care, the program's emphasis (misplaced, in my view) on at
taining method-specific quantitative targets should not be necessary.
The health workers understand this point very well. Their priorities
are therefore quite different from those of their superiors.
The training that health workers receive in the provision of an
tenatal, natal, and postnatal care is an asset. With some reorientation
and additional training, the ANMs can use their skills to offer repro
ductive health care to women with a modicum of additional resources,
provided that their goals are correctly defined. This shift in empha
sis would be beneficial to women and would boost the morale of the
health care providers.
The analysis also brings home a point that has been reiterated
many times in recent years: the Indian program has placed too much
emphasis on method-specific contraceptive targets. From the perspec
tive of health workers, this overemphasis has had an adverse effect
on their performance and their reputation. They feel deeply hurt when
they are rebuked in the presence of other workers for not having ful
filled some of their targets. They also believe that the other good work
166
Quality of Reproductive Health Care in Gujarat
they are doing is undervalued. This narrow focus leads to a neglect
of other health care services. The oft-repeated policy of integrating
maternal and child health care with family planning has not been
implemented because of the program managers' obsession with the
fulfillment of numerical targets.
With respect to the question of the quality of care received by
the Indian populace, and by rural women in particular, the narration
of a recent experience in a remote district is instructive. During our
focus-group discussion with village women, we learned that they
seemed reasonably satisfied with the services they had received from
the health workers. The ANMs we met in a meeting at a PHC also
indicated their overall satisfaction with the supervisors, targets, and
infrastructural facilities at their PHC or community health center
(CHC). The discussion took place in the presence of the PHC medical
officer. After the doctor left, however, the ANMs reported to us that
the borewell in the neighboring CHC had been out of order for sev
eral weeks, and that without water it was impossible to maintain the
expected levels of sanitation and hygiene at the CHC. The entire place
exuded a foul odor, and it was an ordeal to have to work there. We
therefore decided to visit the CHC. When we arrived and tried to
talk to the doctor in charge, we found him uncommunicative. Instead
of talking to us directly, he instructed his clerk to answer our ques
tions. The clerk explained that the prescribed procedures for getting
the borewell repaired were an obstacle to improving the conditions
at the CHC. Sterilizations continued to be performed in the CHC on
the appointed day of the week with a tanker of water commissioned
from the neighborhood. But the limited water supply prevented the
staff from maintaining hygienic conditions, and one of the two wards
had to be shut down, with men and women placed together in one
ward. In this situation, as in others at the sterilization camps, PHCs,
and subcenters, the grassroots health workers expressed concern
about the quality of services provided to their "cases," but they had
virtually no control over the substandard conditions.
The poor in rural areas are so vulnerable that when they seek
help or care, they are generally not knowledgeable about standards
of care, or even the types of assistance they are entitled to receive,
and are grateful for whatever services are rendered to them. It is the
better-informed who must lead in enforcing the appropriate norms
Leela Visaria
167
■I
of behavior for the relatively privileged health care providers, many
of whom seem to observe the Hippocratic oath more in breach than in
practice. Perhaps, if the devolution of powers envisaged under the re
cently enacted Seventy-third and Seventy-fourth Constitutional Amend
ments becomes effective in India, and the panchayats begin to monitor
and supervise the activities of doctors and other health functionaries,
the bureaucratic malaise that currently characterizes the public-sector
program might begin to be challenged and effectively addressed.
•-S
Acknowledgments
This chapter has benefited from comments on an earlier draft by participants in
the Workshop on Quality of Care in the Indian Family Welfare Programme. I
• am especially grateful to Michael Koenig and Pravin Visaria for their comments
and suggestions. Thanks are also due to the field investigators, especially Ila
Mehta and Rita Dave, who helped me collect the data analyzed here; to Jignasu
Yagnik for data management and processing; to Arti Dave for computational
assistance; and to Sheela Devadas, V. A. Vasanthi, and Girija Balakrishnan for
word processing. The responsibility for any errors of fact or interpretation rests
with me alone.
Notes
1
2
3
4
The terms "auxiliary nurse-midwife" and "female health worker" are used
interchangeably, although there is a minor difference between the two. The
ANMs, who received their training earlier than the FHWs, underwent more
intensive training and for a longer period than is now required for the
FHWs. The ANMs surveyed for the current study often mentioned this dis
tinction during their conversations with my colleagues and me, and we
agree that the ANMs are generally better trained and qualified.
Of the 100 ANMs from two of the districts (four villages had two ANMs
each), we were able to contact 88. Six of the 12 nonavailable ANMs were
on maternity leave; the position of the ANM was vacant at the time of the
survey in three villages; and the remaining three workers were reported to
be on leave and could not be contacted. The survey of the health workers
in the other two districts was conducted by another organization, the Op
erations Research Group, in Baroda, under a subcontract. We were pro
vided data for 85 ANMs; the reasons for the nonavailability of 11 or more
ANMs are not known.
More than two-thirds of the villages in the two tribal districts had subcenter
buildings with living quarters for the ANMs. Various donors had provided
the financial resources, and in most cases the village panchayats (councils)
had donated the land.
The distribution of ORS packets to health workers is only a symbolic ges
ture, and their use has not been promoted with any seriousness. Virtually
Quality of Reproductive Health Care in Gujarat
|
none of the village women we interviewed indicated that they had obtained
ORS packets from the health workers.
In another study in Gujarat, reported IUD insertions were found to reflect
only a nominal fulfillment of the targets assigned to the health workers
(Visaria, Visaria, and Jain 1994). The health workers themselves admitted
this to be the case and indicated that they had simply to maintain their
records "properly."
Apparently this is not always the case in some other states of India. Khan
et al. (1994, p. 6) have reported that in Bihar only about 36 percent of the
women surveyed reported having been visited by workers from their PHC
or subcenter.
I
168
5
6
-
I
9
f; ■
References
Bruce, Judith. 1990. "Fundamental elements of the quality of care: A simple
framework," Studies in Family Planning 21(2): 61-91.
Ickis, John C. 1992. "Quality of family planning services in Latin America," in
Managing Quality of Care in Population Programs, ed. Anrudh K. Jain. West
Hartford: Kumarian Press, pp. 67-85.
Jain, Anrudh K., Judith Bruce, and Sushil Kumar. 1992. "Quality of services,
programme efforts and fertility reduction," in Family Planning Programmes
and Fertility, eds. James F. Phillips and John A. Ross. Oxford: Clarendon
Press, pp. 202-221.
Khan, M.E., Rudranand Prasad, Bella C. Patel, and Ram Bachan Ram. 1994.
"Quality of care in Family Welfare Programme from users' perspective,"
paper presented at Seminar on Quality of Care Issues in Health and Fam
ily Welfare, Gujarat Institute of Development Research, Ahmedabad, 2B29 April.
Mensch, Barbara. 1993. "Quality of care: A neglected dimension," in The Health
of Women: A Global Perspective, eds. M. Koblinsky, I. Timyan, and I. Gay.
Boulder, Colo.: Westview Press, pp. 235-253.
Miller, Robert A., Lewis Ndhlovu, Margaret M. Gachara, and Andrew Fisher.
1991. "The situation analysis study of the family planning program in
Kenya," Studies in Family Planning 22(3): 131-143.
Simmons, Ruth and Christopher Elias. 1994. "The study of client-provider in
teractions: A review of methodological issues," Studies in Family Planning
25(1): 1-17.
Simmons, Ruth, Laila Baqee, Michael A. Koenig, and James F. Phillips. 1988.
"Beyond supply: The importance of female family planning workers in ru
ral Bangladesh," Studies in Family Planning 19(1): 29-38.
Visaria, Leela and Pravin Visaria. 1992. "Quality of family planning services in
Gujarat State, India: An exploratory analysis," in Managing Quality of Care
in Population Programs, ed. Anrudh K. Jain. West Hartford: Kumarian Press
pp. 113-140.
Visaria, Leela, Pravin Visaria, and Anrudh Jain. 1994. "Estimates of contracep
tive prevalence based on service statistics and surveys in Gujarat State, In
dia," Studies in Family Planning 25(5): 293-303.
B
Assessing the Quality
of Family Planning
Service Providers
in Four Indian States
I
1
3
RAVI K. VERMA & T. K. ROY
■ ?
*;
1 I
■•j
!
!
’•
■' I
I
n
The quality of care received by women in rural areas depends largely
upon the providers' technical competence and motivation, and upon
how well they are supported by the health system's infrastructure
and logistics. In addition, the personal dimension of services, reflected
in relations between providers and their clients, is crucial to a high
standard of care. According to the quality-of-care framework pro
posed by Bruce (1990), a number of factors strongly influence inter
personal relations; these include program management style, resource
allocation, the ratio of workers to clients, and supervisory structure.
In India the government provides rural health and family wel
fare services mainly through a chain of community health centers
(CHCs), primary health centers (PHCs), and subcenters. The present
infrastructure plan has as its goal one subcenter for every 5,000 in
habitants, one PHC for every 30,000 inhabitants, and one CHC for
every 100,000-120,000 inhabitants. In tribal and hilly areas, one PHC
is planned for every 20,000 inhabitants and one subcenter for every
3,000 inhabitants. Currently there are about 30,000 PHCs and about
131,000 subcenters throughout the rural areas of the country. This net
work of centers offers a host of preventive, promotive, and curative
services to the rural population. In this network, the subcenter staff,
particularly the female outreach workers known as auxiliary nurse
midwives (ANMs), play a crucial role, providing an important link
between the national Family Welfare Programme and its clients. The
169
170
Assessing Quality of Providers in Four Indian States--*—* "3 M
competence of these workers and their level of involvement in their
work are critical to the effective implementation of the program.
Although several factors affect the utilization of primary health
care services and the acceptance of family planning methods, the in
volvement of personnel, especially of ANMs, is one of the major de
terminants. Poor working conditions and inadequate facilities in ru
ral areas have produced dissatisfaction among health functionaries,
including doctors, which has adversely affected their involvement
(Jagdish 1981). Varying levels of job satisfaction among personnel have
been demonstrated even in relatively well-off states such as Kerala
(Baburajan and Verma 1991). Recent studies using the quality-of-care
framework underscore the need for a comprehensive study of the
quality of service providers and their perceptions of key aspects of
service delivery (Cernada et al. 1992; Koenig, Hossain, and Whittaker
1997; Visaria and Visaria 1992). This chapter addresses that need by
describing the dimensions of service provided by ANMs that can have
a profound influence on the quality of family welfare care delivered
to rural Indian women.
Data and Methodology
'r
171
Ravi K. Verma • T. K. Roy
K- .
TABLE 9.1
Selected characteristics of ANMs: Four Indian states, 1994
I
Characteristic
. &
Bihar
West Bengal
Tamil Nadu
Karnataka
47
26
17
38
8
34
36
23
37
14
50
20
17
35
5
47
33
16
36
0
100
(68)
20
80
(92)
28
72
(72)
12
88
(60)
Age (years) (%)
<25
H
25-34
35-44
44+
Average age (years)
p
Marital status (%)
Unmarried
Married
(No. of ANMs)
I
Note: Percentages may not add to 100 because of rounding
ANM=auxiliary nurse-midwife.
Findings
The analysis compares by state the respondents' answers to questions
about program facilities, support for their work, and the other ele
ments of quality of care, based primarily on the perceptions of the ANMs.
»
J'
Worker Characteristics
£
Our analysis is based upon data from four states: Tamil Nadu and
Karnataka in the south, and West Bengal and Bihar in the north. The
data come from two studies conducted under the auspices of the In
ternational Institute for Population Sciences (UPS), Mumbai (Verma
and Roy 1994; Verma, Roy, and Saxena 1994).1 Given the available
resources for the two studies, we selected three districts in each of
the four states, with districts chosen primarily on the basis of their
family planning performance. Aiming to capture the range of service
quality in those states, we selected one district each from the high,
medium, and low categories of performance. After ranking all PHCs
in each district according to their performance, we chose two PHCs
in the high, medium, and low categories of performance from each
district, for a total of 18 PHCs per state. At each PHC, we interviewed
the medical officer-in-charge, all supervisors, and at least three ANMs
out of an average total of six. Altogether, 292 ANMs were inter
viewed—68 in Bihar, 92 in West Bengal, 72 in Tamil Nadu, and 60 in
Karnataka.
si
■ ®
p-'
11 ■
' I
11
i g.
■
As Table 9.1 indicates, slightly more ANMs in Tamil Nadu than in
the other three states were under age 25. In all states, the mean age of
ANMs was in the mid-30s. Unmarried workers constituted 28 per
cent of the sample in Tamil Nadu, 20 percent in West Bengal, and 12
percent in Karnataka; in Bihar, all interviewed workers were married.
Population Served and Facilities and
Support Available to ANMs
The average population served by a Pl 1C in Tamil Nadu was around
30,000, conforming to the prevailing norm (Table 9.2). In Karnataka
the average population size per PHC was slightly higher (38,000). In
both Bihar and West Bengal, PHCs were serving much larger aver
age populations—141,000 and 166,000, respectively. As a result, an
average PHC in Bihar was catering to slightly more than three times
the number of villages served by an average PHC in Tamil Nadu. As
villages tend to be more remotely situated in Bihar and West Bengal
172
Assessing Quality of Providers in Four Indian States
Ravi K. Verma • T. K. Roy
TABLE 9.2
Populations served and types of facilities and support at 72 PHCsFour Indian states, 1994
P
CS*
Population served and types
of support available at PHC
Average population
served by PHC
Average no. of villages
served by PHC
Percentage of PHCs with:
Adequate number of personnel
Operation theater
Roadworthy vehicle
Toilet
Drinking water
(No. of PHCs)
Bihar
West Bengal
Tamil Nadu
I
f
Karnataka
141,000
166,000
30,000
38,000
136
133
41
63
50
83
83
33
22
(18)
6
83
83
38
27
(18)
50
33
50
38
50
(18)
1 II
I-
I'
!■
50
56
61
38
55
(18)
Information given to oral contraceptive clients during initial meeting:
Four Indian states, 1994
Type of information
provided by ANMs
Discuss client's reproductive goals
Explain how to use pill
Bihar
21
22
Percentage of ANMs
West Bengal
Tamil Nadu
17
36
32
Discuss side effects
18
40
37
Advise about subsequent checkup
28
(68)
24
(92)
(No. of ANMs)
Karnataka
55
37
38
14
58
(72)
(60)
32
ANM=auxiliary nurse-midwife.
I
The Quality of Family Planning Services
Provided by ANMs
PHC=public health center.
than in Tamil Nadu and Karnataka, the logistical demands on work
ers in the former states were considerably higher.
00^7^ t0
CUrrent nOrm' 3 PHC C°Vermg a Population of
30,000 should have a mmimum of three medical officers, one block ex
tension educator, and two ANMs. The availability of personnel, both
medical and paramedical, was problematic in all four states. In Bihar,
Tamil Nadu, and Karnataka, only one-half of the PHCs were adequately
staffed, and in West Bengal just one PHC (6 percent) was at the minimal
staffing level. In Tamil Nadu, only a third of the PHCs had an operation
theater (OT) and only half of them had a roadworthy vehicle A major
ity of the PHCs in Karnataka had an OT and a functioning vehicle, but a
significant minority had neither. Although PHCs in Bihar and West Ben
gal were somewhat better off in this respect, in both states the PHCs serve
much larger populations than their counterparts in the other two states.
In addition to medical facilities, we explored the availability of
other service-related facilities at the PHCs. Service-related facilities
include seating for staff and clients, a private examination room, a
private consulting room, a toilet, and drinking water. Of these the
availability of toilet and drinking water facilities are most basic'and
essential. A majority (62-67 percent) of the PHCs in all four states
lacked toilet facilities. The situation with respect to drinking water was
somewhat better in Tamil Nadu and Karnataka, where 50 and 55 per
cent of PHCs, respectively, had this amenity. In Bihar and West Bengal
however, only 22 and 27 percent of PHCs had drinking water.
'
TABLE 9.3
-
*
To assess the quality of family planning services provided by ANMs,
we asked questions designed to measure the following dimensions
of quality: (1) the information that ANMs provided to their clients;
(2) the choice of contraceptive methods available to clients; (3) ANMs'
knowledge and technical competence; and (4) mechanisms used to
ensure follow-up. We also explored whether an appropriate constel
lation of services was present and the extent of support ANMs re
ceived from their supervisors and their job commitment.
Information to clients. The information imparted by providers dur
ing interactions with clients can be a crucial element of the overall
quality of care provided. For example, it is important that while sug
gesting a family planning method, the provider inform the client about
its possible side effects and the measures to be taken in case the cli
ent experiences a reaction to it. We queried ANMs about the type of
advice they would give clients who showed a willingness to use pills
for the first time. Their responses suggest that the range of information
given to clients leaves considerable room for improvement (Table 9.3).
Only in Karnataka did a majority of ANMs (55 percent) indicate
that they discussed the client's reproductive goals. In Tamil Nadu
one-third said they did so, and in Bihar and West Bengal the propor
tions were one-fifth or less. With the exception of West Bengal, even
fewer respondents said they gave detailed instructions to a client on
how to use the pill. Karnataka was the only state where a majority of
workers (58 percent) seemed to be concerned about the possible side
effects of the pill. In the other three states fewer than two in five ANMs
174
Assessing Quality of Providers in Four Indian States
indicated they discussed side effects with a prospective pill acceptor.
Few ANMs mentioned that they advised clients to have a checkup
within a month, the proportions ranging from 32 percent in Karnataka
to 14 percent in Tamil Nadu. These findings suggest that the need to
impart such information was not uppermost in the minds of the
ANMs; in fact, they appeared to be largely unconcerned about this
aspect of services.
Choice of methods. The Family Welfare Programme offers male
and female sterilization, the Copper-T intrauterine device (IUD), oral
contraceptives (pills), and condoms. In 1961 it adopted a cafeteria ap
proach to enable clients to select contraceptive methods suited to their
needs. In theory, the approach provides Indian couples with a wide
choice of methods. In practice, however, a client, particularly if illit
erate, may not be able to exercise his or her own preference in select
ing a method. The choice of method will be limited if the provider
suggests a particular method and especially if the provider actively
promotes one method and fails to mention others. To understand the
extent to which clients in our study areas were free to choose a
method, we sought the views of the ANMs regarding the degree of
method choice—whether they informed their clients of all available
methods and encouraged them to choose a method on their own, or
instead recommended a specific method. Most ANMs in the four
states reported that they normally chose the method for the client
(Table 9.4). This response was most common in Karnataka (93 per
cent), but in the other three states roughly three-quarters of the ANMs
said they generally chose the method for their clients.
Workers indicated that they were most likely to recommend fe
male sterilization, the IUD, and, to a lesser extent, the pill. In
Karnataka three-fourths or more of the ANMs mentioned that they
were likely to offer those three methods, whereas fewer than half (45
percent) suggested condoms and only 15 percent included male ster
ilization in the list of methods generally suggested. In West Bengal
more ANMs (about two-thirds) said they offered spacing methods
(the IUD and pills) than female sterilization or condoms (about half).
If their replies accurately reflect their actions, then method choice ap
pears to be greater in West Bengal than in the other three states es
pecially Tamil Nadu. In Tamil Nadu the workers seem to have pro
moted only two methods, female sterilization and the IUD. Only a
t-
175
Ravi K. Verma • T. K. Roy
TABLE 9.4
Contraceptive method choice: Four Indian states, 1994
Method choice
indicated by ANMs
Who chooses family
planning method?
Provider
Client
Method generally recommended
Female sterilization
IUD
Oral contraceptives
Condoms
Male sterilization
Periodic abstinence (rhythm)
<
Pressure on ANMs to achieve
method targets
Female sterilization
High
Moderate
None
Spacing methods
High
Moderate
None
(No. of ANMs)
_____________ Percentage of ANMs
Bihar
West Bengal
Tamil Nadu
Karnataka
75
25
74
26
73
27
93
7
68
66
53
41
15
0
53
67
64
50
11
0
69
61
33
7
3
0
82
88
75
45
15
0
53
37
11
49
29
22
94
6
0
40
44
16
43
23
34
(68)
32
57
11
(92)
52
42
6
(72)
34
51
15
(60)
ANM=auxiliary nurse-midwife; IUD=intrauterine device
!■
s
third of them suggested the pill, and few if any workers suggested
other methods such as condoms or rhythm.
How aggressively ANMs promote a method depends largely
upon the amount of pressure they perceive to attain program targets
for that method. The third panel of Table 9.4 shows that substantial
majorities of workers in all four states felt themselves to be under at
least some pressure to recruit targeted numbers of female steriliza
tion acceptors. Nearly all workers in Tamil Nadu (94 percent) reported
the existence of high pressure. In the remaining three states approxi
mately one-half of the workers perceived the pressure to be high. Most
workers in all the states felt less, but still substantial (high or moder
ate), pressure to achieve the government's targets for spacing meth
ods as well.
Not surprisingly, contraceptive use in the four states follows a
pattern similar to this program influence. According to the 1992-93
National Family Health Survey, the proportion of women contracep
tive acceptors who were using either female sterilization or the IUD
17b
Assessing Quality of Providers in Four Indian States
I K;
TABLE 9.5
Technical knowledge and competence of ANMs: Four Indian states, 1994
■
Technical knowledge and
competence indicators
Responded correctly
When are the chances of
conception highest?
What is a tubectomy?
When to recommend medical
termination of a pregnancy?
Attended refresher course
Found training to be adequate
(No. of ANMs)
Bihar
Percentage of ANMs
West Bengal
Tamil Nadu
i
B
Karnataka
56
69
39
80
86
90
64
68
79
46
68
(68)
73
65
57
(92)
94
72
98
(72)
93
57
47
(60)
Hi M
g||
III
ANM=auxiliary nurse-midwife.
(mostly the former) was 90 percent in Karnataka, 82 percent in Tamil
Nadu, 77 percent in Bihar, and 48 percent in West Bengal (IIPS 1995).
Technical knowledge and competence. Our study also assessed
ANMs' technical competence by asking a set of questions about such
topics as the time in the menstrual cycle when conception was most
likely to occur, female sterilization (tubectomy), and when to recom
mend the medical termination of a pregnancy (Table 9.5). Rather dis
appointingly, substantial proportions of workers in West. Bengal (61
percent), Bihar (44 percent), and Karnataka (36 percent) did not know
the point in the menstrual cycle when a woman faced the greatest
risk of becoming pregnant. In Tamil Nadu the proportion of workers
with incorrect knowledge on this issue was low (14 percent). Higher,
but still far from universal, percentages of ANMs had accurate knowl
edge about tubectomy or when to recommend an abortion. Given the
Family Welfare Programme's recent emphasis on promoting spacing
methods of contraception, the workers' lack of knowledge about ba
sic reproductive physiology is a matter of serious concern.
Contributing to their knowledge gap is a lack of follow-up train
ing. Only 46 percent of ANMs in Bihar, 57 percent in Karnataka, and
65 percent in West Bengal had undergone a refresher training course;
in Tamil Nadu the proportion was higher, at 72 percent. The perceived
usefulness of refresher courses also varied widely across states. In
Tamil Nadu almost all the workers who had attended a course (98
percent) found that the training had been adequate, and in Bihar two-
p
Bl-
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H
8
|
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* B
•; I.,
T
Ravi K. Verma • T. K. Roy
thirds were satisfied with the refresher course. In Karnataka fewer
than one-half of such workers thought that the course had been ad
equate, and in West Bengal only 57 percent held this view.
Mechanisms for follow-up. Client follow-up and efforts to promote
continued contraceptive use are vital to maintaining a high quality
of care. Proper follow-up begins with systematic record-keeping and
inculcating among health workers a concern and responsibility for
this activity. While interviewing the ANMs, investigators also attempted to assess whether the addresses of clients in their eligiblecouple registers were adequate to allow follow-up. We also asked
ANMs questions designed to measure the extent to which they felt
pressure to attain their follow-up targets and whether they provided
follow-up to clients during home visits. To assess their actual prac
tices regarding continuity of care, we asked them how many clients with
problems had contacted them during the previous month (Table 9.6).
Although about one-half of the workers in Karnataka and West
Bengal maintained their registers to permit client follow-up, in Bihar
and Tamil Nadu only about: a third of the workers were doing so.
The proportions of workers who reported providing follow-up dur
ing home visits were much lower, especially in Bihar (15 percent) and
Tamil Nadu (18 percent). In West Bengal and Karnataka, 41 and 50
percent of the workers, respectively, reported providing follow-up.
Fewer workers in each state felt pressure to provide follow-up care
than to achieve sterilization targets (compare Table 9.6 with Table 9.4).
Only 16 percent of workers in Bihar, 26 percent in West Bengal, 32
percent in Tamil Nadu, and 40 percent in Karnataka felt such pres
sure. Nearly one-half of the ANMs in Bihar, West Bengal, and Tamil
Nadu reported that clients having problems with their family pl anning method had contacted them during the previous month; but in
Karnataka only 12 percent of the workers reported such contact. Of
those who had been contacted by family planning clients during the
previous month, most reported seeing only one or two clients. Only
in West Bengal did a substantial percentage of ANMs report having
been contacted by three or more clients.
Appropriate constellation of services. One determinant of the qual
ity of family planning services is the location of an appropriate con
stellation of services for clients. We attempted to gauge the constella
tion of services by asking the workers where they had referred clients
178
Assessing Quality of Providers in Four Indian States
Ravi K. Verma • T. K. Roy
TABLE 9.6
Mechanisms for follow-up: Four Indian states, 1994
Mechanism
Maintains detailed addresses in
register for follow-up of couples
Provides follow-up during
home visits
Feels pressure to provide
follow-up care
Bihar
Percentage of AN Ms
West Bengal
Tamil Nadu
TABLE 9.7
E
Measure of constellation of services: Four Indian states, 1994
-------Percentage of ANMs
Measure
Bihar
West Bengal
Tamil Nadu
i
Karnataka
•
I
b J
32
48
39
53
15
41
18
50
16
26
32
40
Number of family planning clients
with problems contacting ANM
during previous month
None
1-2
3-4
5+
53
39
8
0
53
23
10
15
51
36
10
3
88
6
3
3
(No. ofANMs)
(68)
(92)
(72)
(60)
Note: Percentages may not add to 100 because of rounding.
ANM=auxiliary nurse-midwife.
||
ilL
during the month before they were interviewed, most of the workers
in the study area had referred clients with problems to the PHC and
did not revisit them. In all of the states, only a small minority of ANMs
(9-19 percent) reported that they themselves had revisited clients having problems.
■i-
2.
Place of residence
Village staff quarters
15
Other quarters in PHC village
53
Outside village
32
Referrals
Referred clients with problems
to PHC
72
Revisited clients having a problem 16
Neither referred nor revisited
clients having a problem
12
j
| j&j
(No. of ANMs)
(68)
Karnataka
11
30
59
33
58
8
38
42
20
65
19
80
9
86
14
16
11
0
(92)
(72)
(60)
N°te: Percentages may not add to 100 because of rounding
|i "F
ANM=auxiliary nurse-midwife; PHC=primary health center.
I■ '
|
«
with problems who had contacted them during the previous month.
We also asked about the location of each worker's residence—whether
she lived within the village to which she was assigned (in staff quarters or other quarters) or outside the village. The location of an ANM's
residence has a direct bearing on her ability to provide effective and
accessible care.
Housing accommodations for the workers were found to be poorer
in the northern than in the southern Indian states (Table 9.7). In West
Bengal only 11 percent of the workers reported that they were residing
in staff quarters, and another 30 percent were living in the village where
their PHC was located; most (59 percent) were living outside the village.
In Tamil Nadu, by contrast, 91 percent of the workers» were residing
within the PHC village, and a tliird were living in staff quarters.
Simi
s. Similarly, in Karnataka 38 percent of the workers were housed in govern
ment quarters, and 80 percent were residing within the PHC village.
Poor availability of services is also evidenced by the finding that
179
lb
I Bi
f.
I
g?;
I
9
1I hER
I H
I
I
| J'
I/'
1 fc
Supervisory support and job commitment. Effective supervision is
essential for supporting ANMs anu
and iitripiiig
helping them
improve their
caacnuai
nielli to
IO lllipruve
lilt
work performance. We were therefore interested in learning heow
regularly
regularly supervisors
supervisors made
made contact
contact with
with the
the ANMs
ANMs and
and how
how tthe
’
..........................................
workers perceived the activities of their supervisors during visits to
the field. According to the ANMs, their work was supervised in most
cases, although the percentage reporting supervision varied from a
high of 87 percent in Tamil Nadu to a low of 60 percent in Bihar (Table
9.8). Only one-fourth of the workers in Tamil Nadu mentioned that
thei:ir supervisors gave them guidance for improving their perform
ance, and only about one-tenth of them reported that their supervi
sors attended to clients' problems. Supervisors in Karnataka and West
Bengal appear to have been more effective than those in Bihar or Tamil
Nadu. About one-half of the workers in Karnataka reported that supervisors gave them advice on improving their performance and also
attended to their clients' problems. In Bihar only 15 percent of the
workers reported that the supervisors guided them to perform bet
ter, and only three in 10 reported that their supervisors attended to
clients' problems,
To
To gauge
gauge Ab
ANMs' levels of motivation and job commitment, we
also
alsoinquired
inquiredaboi
about their willingness to continue working in the Fam
ily Welfare Progr
ily Welfare Programme and in the same PHC area. Their responses
suggest that a majority of ANMs in all four states were motivated to
180
Assessing Quality of Providers in Four Indian States
Jggi
TABLE 9.8
Supervisory support and job commitment: Four Indian states, 1994
Supervisory support
and job commitment
Type of supervisory support
(as reported by ANMs)
Superior supervises work
Gives guidance on
performing better
Attends to clients’ problems
ANM’s job commitment
Prefer not to switch to another
government job
Prefer not to switch to
another PHC
(No. of ANMs)
_____________ Percentage of ANMs
Bihar
West Bengal
Tamil Nadu
Ravi K- Verma • T. K. Roy
Karnataka
60
71
87
75
15
29
37
47
25
13
53
48
68
54
66
65
59
74
(68)________ (92)
57
(72)
57
(60)
ANM=auxiliary nurse-midwife; PHC=primary health center.
remain in their jobs. Two-thirds of those in Bihar, Tamil Nadu, and
Karnataka and slightly more than one-half in West Bengal said they
would not want to switch to another job even if such an opportunity
came their way. Substantial majorities of ANMs in all four states said
they were not willing to switch to another PHC area. Nevertheless, about
two-fifths of the workers in Bihar, Tamil Nadu, and Karnataka and onefourth in West Bengal were in favor of changing their work location.
Summary and Conclusion
This chapter has examined, from the perspective of service provid
ers, a number of elements of service delivery that have a direct bear
ing on the overall quality of family welfare services. The analysis has
provided insights into the quality of family planning services and care
available in four states of India. We found considerable variation
among the four states in these quality-of-care variables. Overall, the
coverage of services in Tamil Nadu and Karnataka appeared to be
better than those in Bihar and West Bengal, as judged by the average
size of the populations served, the ratio of personnel to population,
the availability of living quarters for the workers, and the adequacy
of the PHCs' medical and service facilities. Workers in those two states
also appeared to be more knowledgeable and technically more com
petent than those in West Bengal and Bihar.
However, in all four states the quality of services and care pro
vided appears to fall far below desired levels. Instead of informing
clients about all available family planning methods, most ANMs Io
cusedI on one or two methods, notably female sterilization and the
IUD. The quality of care as reflected by the type of information pro
vided to clients was also low. When asked what kinds of information
or advice they would give to a pill acceptor, most workers failed to
mention side effects or returning for a checkup. In fact, for most of
the workers, follow-up care does not appear to have been a priority,
possibly because they felt pressure to concentrate on meeting targets
for new acceptors. The apparent widespread gaps in many aspects of
• quality of care in all four states suggests that program managers need
place increased emphasis> on the training and support of this key
i_________ i_ _ i_________ 1
cadre of ______
workers
who have direct contact with, and responsibility for,
WEte the population that the program is intended to serve.
■
f
la
Kr
.
..
a
Acknowledgments
' ife ■
I'
Thanks are due to the International Institute for Population Sciences and the
United States
Agency
for International Development for their support of the
_______
o ____
research reported here. We» are grateful to Michael Koenig for his useful com
ments on an earlier version of this chapter and to Dr. S. K. Singh, Mr. S. Praveen,
Mr. Somnath, and Mr. M. Mainkar for their assistance on this project.
f
Note
I ■
1
• R-
w
Data for Tamil Nadu, Karnataka, and West Bengal are from a study en
titled Quality of Family Welfare Services and Care in Selected Indian States,
which UPS undertook in 1994 with financial assistance from the United
States Agency for International Development (USAID). The data for Bihar
are from a 1995 UPS study entitled Quality of Family Welfare Services and
Care in Bihar. (See Verma and Roy 1994; Verma, Roy, and Saxena 1994.)
References
j fe:
r
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- V
1I i?
Baburajan, P.K. and Ravi K. Verma. 1991. “Job satisfaction among health and
family welfare personnel: A case study of two primary health centres in
Kerala," Journal of Family Welfare 37(2): 14-23.
Bruce, Judith. 1990. "Fundamental elements of the quality of care: A simple
framework," Studies in Family Planning 21(2): 61-91.
Cernada, George P., A.K. Ubaidur Rob, I.A. Safia, and A.M. Shafiq. 1992. "Ac
cessibility and availability of family planning services in Pakistan: 1992,"
Demography India 21(2): 213-238.
International Institute for Population Sciences (UPS). 1995. National Family Health
Survey (MCH and Family Planning): India, 1992-93. Bombay (Mumbai): UPS.
182
Assessing Quality of Providers in Four Indian States**^
Ja8d218<l19981 ZTrimary health Care in rural India'" World Health Forum 2(1):
Koenig, Michael A., Mian Bazle Hossain, and Maxine Whittaker. 1997. "The in
fluence of quality of care upon contraceptive use in rural Bangladesh " Stud
ies in Family Planning 28(4): 278-289.
Verma, Ravi K., and T.K. Roy. 1994. Quality of Family Welfare Services and Care in
Bihar. Bombay (Mumbai): International Institute for Population Sciences.
Verma, Ravi K., T.K. Roy, and P.C. Saxena. 1994. Quality of Family Welfare Ser
vicesand Care in Selected Indian States. Bombay (Mumbai): International In
stitute for Population Sciences.
Visaria, Leela, and Pravin Visaria. 1992. "Quality of family planning services in
Gujarat State, India: An exploratory analysis," in Managing Quality of Care
in Population Programs, ed. Anrudh K. Jain. West Hartford: Kumarian Press
pp. 113-140.
I|
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I!
•
rh
II
I’
i
10 Constraints to the
Quality of Primary Health Services
in Rural Karnataka
JAGDISH C. BHATIA
i
'3 I
r-
■
■
11
II
■ r
r
■ L
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Primary health centers (PHCs) are the focal points for the delivery of
comprehensive health and family welfare services to the rural popu
lation of India. PHCs were established in 1952 as part of a national
community development program. Their incorporation into the pro
gram was aimed at ensuring community participation and inter
sectoral coordination needed to bring about improvements in the
health status of the people. These functions were broadly categorized
as medical relief, control of communicable diseases, environmental
sanitation, maternal and child health (MCH), family planning (now
called family welfare), school health, health education, and vital sta
tistics (Dutt 1965). Later additions to their activities and the expan
sion of many vertical health programs resulted in a substantial in
crease in staff numbers, from an initial 10-12 staff to 40-50 staff.
Although PHCs have been in existence for more than four dec
ades, they have had only limited success in achieving their objectives.
The utilization of their services by communities has frequently been
poor. Several studies indicate that only 10-20 percent of rural inhab
itants use PHCs' medical facilities (Chuttani et al. 1976; Johns Hopkins
University, Department of International Health 1976; Khan 1989). Ef
fective coverage by PHCs is restricted largely to villages within a dis
tance of five kilometers (Udupa 1991). The utilization of MCH ser
vices provided by the PHC has also been poor (Bhatia 1993; Kanitkar
and Sinha 1989; Ramachandran 1989). The environmental education,
health education, school health, and vital statistics components of PHC
183
184
Jagdish C. Bhatia
Constraints to Service Quality in Rural Karnataka
services receive hardly any attention from PHC staff (Chuttani et al.
1976; Ghosh 1992; Parker, Murthy, and Bhatia 1972). The only func
tion to which workers devote significant time is family welfare, pri
marily because of the enforcement of family planning targets and the
availability of monetary incentives for family planning. But even the
quality of family planning services at the PHC level has been found
to be poor (ICMR1991). Several studies have attributed the poor qual
ity of PHC services to logistical problems, and especially to person
nel problems, such as poor involvement and low morale of periph
eral workers.
PHCs have a poor image or are unknown in many communi
ties. Studies have shown that awareness and use of PHC and subcenter
facilities are limited to the villages where services are located. People
living in peripheral villages either are unaware of the services or find
it difficult to reach them because of poor transport facilities and dis
tance. Apart from doctors, the PHC system has a battery of health
workers, both male and female, who are supposed to make domicili
ary visits regularly in all villages in their respective areas. A large
proportion of the people in the rural areas, however, have been found
to be unaware of their existence (Bhatia 1986; Chuttani et al. 1973).
Even among the small proportion of villagers who have used the
facilities, a majority have expressed dissatisfaction with the services,
mainly because of the nonavailability of medicines and the rude and
impersonal behavior of the doctors (Chuttani et al. 1973). Consequently
villagers patronize traditional medical practitioners, who are not nec
essarily using traditional herbs, oils, and incantations; on the contrary,
they are increasingly using modern medicines (Bhatia et al. 1975;
Neumann et al. 1971). They also provide family planning and abor
tion services to their clients (Bhatia 1973; Bhatia et al. 1974; Neumann
and Bhatia 1973). They are popular among rural communities, and
their numbers are growing rapidly. People willingly pay for their ser
vices rather than seek the free services provided by the PHC system.
Previous Research on the
Indian Primary Health Care System
Misra and colleagues (1982) carried out an empirical study of PHC
health providers in several districts of Uttar Pradesh. The systematic
organizational diagnosis of the Family Welfare Programme's imple-
!
I
F
I
j
J
1
h-
l
t
r
r
r
mentation at the PHC and higher organizational level used primary
data collected from the users of services in rural areas, service pro
viders at the PHC level, and personnel at higher administrative lev
els. The study found that poor motivational levels of staff for rural
work, lack of effort by field staff, and inadequate systems for induc
ing work effort were the main causes for the PHCs' poor performance.
The study also found that strategies to meet clients' needs could not
be developed because of weak links between the various levels of
health care administration.
Another study, conducted in two subdistricts of Karnataka, ana
lyzed organizational aspects of family planning at the PHC level as
part of a broader investigation of the organization of rural develop
ment (Ray 1976). Such factors as coordination and communication
between field staff and higher echelons of administration were found
to be significant determinants of performance effectiveness. In addi
tion, the autonomy and participation of field staff in the decisionmaking
process were found to be major factors in the success of the Family
Planning Programme (the name of which was changed to Family Wel
fare Programme in 1977).
A recent study examined the qualitative aspects of family plan
ning and MCH inputs in four districts of Gujarat, using focus-group
interview techniques (Shariff and Visaria 1991). The selection of PI ICs
and subcenters within the districts was based on couple-protection
rates and target-achievement levels. The study found a positive asso
ciation between the quality of inputs and the performance of PHCs.
Poorly performing PHCs were badly maintained and lacked
infrastructural facilities. A large number of female health workers in
those PHCs were not residing at their headquarters, even in districts
where living quarters were provided. Follow-up services were inef
fective, and many of the PHCs charged clients for their services.
The relationship between job satisfaction and organizational
problems of PHC personnel was examined in a study conducted in
five districts of the India Population Project in Karnataka (Narayana
and Reddy 1980). The results indicate that the workers' level of job
satisfaction depended on the frequency of their interactions with, and
guidance from, supervisory personnel.
A study of auxiliary nurse-midwives (ANMs) at PHCs and staff
nurses in rural hospitals of Maharashtra found that the ANMs had a
poor social image within their communities and experienced many
186
Constraints to Service Quality in Rural Karnataka
Jagdish C. Bhatia
problems in their day-to-day work (fesani 1990). While studying the
work priorities and preferences of the ANMs, the investigator found ■ w
that those functionaries had to take extra measures to achieve their
family planning targets. They took special care of the
clients' fami
__________
1
lies, provided transport to the clients and their relatives, and gave
nes,
?
extra money to clients. About one-half of the respondent ANMs
wanted their work to be more holistic than merely seeking to achieve
family planning targets, which was (and despite official policy, largely
remains) the current practice.
A study conducted in several states of India investigated the level
of job satisfaction among PHC personnel (Gupta et al. 1987). Most
respondents expressed dissatisfaction with their housing, educational
facilities for their children, and opportunities for career development.
Although older and male respondents expressed higher levels of sat
■ B
• E
isfaction than did younger and female personnel, most respondents
expressed dissatisfaction with their opportunities for promotion and
I?-professional growth. A large proportion objected to the use of "un
■! K
reasonable pressure" to achieve their targets within a stipulated pe
riod of time, [lack of] freedom to make mistakes and learn from
them, and inequitable compensation for work.
Other studies have reported on the job satisfaction of primary
health care personnel (Paliwal and Sawhney 1982; Rastogi 1978; Satia
1976). A more recent study compared levels of job satisfaction among
health and family welfare personnel at two PHCs in Kerala (Baburajan
and Verma 1991). The PHCs were selected on the basis of their perfor
mance (one having high performance, the other low), and 88 workers
H
Hjwere interviewed. The study revealed differences between the two
PHCs in the leadership qualities and style of their medical officers.
Those in the high-performing PHC were more democratic in their out
look and tended to delegate responsibilities to achieve organizational
objectives. The level of employee satisfaction was also found to be
higher. The results of a multivariate analysis indicated that having con
fidence about receiving a promotion was the single most important
J'r ’
variable accounting for job satisfaction.
An evaluation of a pilot primary health care project in Punjab in
*
1979 revealed that the project placed too much emphasis on clinical
aspects and too little emphasis on preventive and promotive aspects
L
of its work (Bose and Desai 1983). Project personnel lacked an orien
tation in community health and were not able to use their skills fully.
■1
ft-'2
TA7C1 n
Fl-* /'M
ta
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. •
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.
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187
The level of frustration among the staff was found to be high. The
time and energy of multipurpose workers was largely wasted on the
collection, compilation, and maintenance of data rather than spent
on providing direct services to the community.
A nationwide study evaluating family planning services at the
PHC level found an inadequate supply of drugs (particularly at the
subcenters) and supplies (ICMR 1991). The study also found that the
coverage and quality of care administered by ANMs in the field were
inadequate and limited to administration of tetanus toxoid injections
and distribution of folic acid tablets.
Data
As the studies reviewed above indicate, numerous factors influence
the quality of health services. To ensure a satisfactory quality of pri
mary health care, it is essential to identify the constraints in a par
ticular setting as a prerequisite to improving the quality of services.
This chapter aims to identify and understand constraints to high-qual
ity family welfare services in rural Karnataka, from the perspective
of service providers. The data on service providers included in this
chapter originate from two studies in rural Karnataka, conducted by
the author under the auspices of the Indian Institute of Management
during 1994-95.
The first source of data is a time-utilization study of service pro
viders. This study was conducted in a rural PHC in Kolar District of
Karnataka that served 70 villages having a combined population of
about 30,000. The time utilization of PHC staff was studied by work
sampling and continuous-observation techniques. The activities of the
headquarters staff were observed by a researcher using work-sam
pling techniques, whereas the workers at the grassroots level were
continuously observed by graduate interviewers who were intensively
trained. The observers accompanied the workers on their field visits.
The observations continued for a period of 45 working days.
The second data source consists of focus-group discussions with
key staff at the PHC and subcenters, including medical officers, lady
health visitors (LHVs), and ANMs. The research team prepared a list
of topics and compiled a list of staff in each of the two districts. These
lists were used to randomly select four focus groups from each dis
trict_ two consisting of ANMs and one each composed of LHVs and
188
W-
Constraints to Service Quality in Rural Karnataka
medical officers. Each discussion group had approximately 10 par
ticipants. The topics selected for discussion were presented as ques
tions and thoroughly pretested to ensure that the wording of the ques
tions was clear and appropriate, and that the questions elicited
discussion. The focus-group discussions, which the author led with
the help of two moderators, took place at the main hospital in Kolar
District and at the Population Centre in Bangalore. All have had ex
tensive experience-----carrying
inves
unu out in-depth and anthropological Hiveswith health systems research. The distigations and are conversant
<
ANTMc and tLHVs --------------.i i in
. the local
cussions with thep ANMs
were conducted
language, whereas those with the medical officers were conducted in
English. All discussions were tape-recorded and later transcribed,
translated into English, and analyzed for content.
ANMs who do not reside at the PHC headquarters are able to
spend only limited time in the villages covered by them and are not
able to
auxe
tu visit
vxoxc «xx
all priority households.• 1.1
Moreover,
-------------they
---- -spend
r--l an average
ageof
of two
two hours
hours aa day
day traveling
travelingbetween
between their
their residences
residences and
and workworkplaces and approximately RslOO per month on transportation. They
11
*111
1 ’
M M ... 1— *
X- 1
1
“\
k
are not usually
available to attend deliveries, which take place at odd
1 K ; hours. Their nonresidence acts> as a barrier to building confidence and
rapport
with the community.
establishing
o -ri----- ------✓ Focus group discussions
'JKt
reached the conclusion that ANMs who do reside at their respective
||1 headquarters r»mvidp
provide hnttpr
better qprvices
services than those who must commute
1
z
1_
’W
totheiriobs-
In
contrast-to the
i.-------------- - ANMs, most LHVs who took part in the study
reported residing at their PHC headquarters, either in the quarters
provided by the governmentt or in rented houses. Most live in the
\
_ __ ___________________
villages
where the PHCs are headquartered,
which1 are larger lhan
surrounding villages and have better facilities. Those who stay in
rented accommodations outnumber those who stay in the PHC quar-
"I hEB ’ 1
; P
- fc-
Results
The results of our study identify a number of significant impediments
to improved quality of health and family welfare services in the pub
lic sector in Karnataka. Evidence on each of these issues is consid
ered separately.
Jin
& ■
I
B
Staff Residential Quarters
The most common problem mentioned by providers was the lack or
inadequacy of living quarters at the villages served by the PHCs and
subcenters. This problem has forced many of them to reside outside
their assigned PHC headquarters. Most workers commute to their
places of work by public transport, which is often irregular, expen
sive, and time-consuming. The problem is acute for ANMs. Some
subcenters have no buildings, but instead are located in rented single
room accommodations that have no basic facilities, such as water, sani
tation, or electricity. ANMs' living quarters, where provided, also lack
these facilities. Consequently most of the quarters remain unoccupied,
and the ANMs live in nearby towns. A few workers mentioned that
they did not reside near their headquarters because the villages in
which the headquarters were located lacked an adequate school for
their children. Another reason for living elsewhere was that the work
ers did not want to be separated from their husbands.
Jagdish C. Bhatia
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ters. Their rent averages Rs200 per month.
Most medical officers also do not reside at their headquarters,
and this adversely affects their work routines. Because lluy spend
considerable time commuting, they are able to spend little time al
the PHC and rarely make outreach visits. Several medical officers told
that, although they had strict instructions from their superiors to
stay at the headquarters, they were unable to do so because of the
lack of adequate living facilities or schools for their children. They
were therefore forced to rent houses in the taluka (subdistrict) town,
pay high rents, and commute daily to the PHC headquarters. As one
female medical officer reported:
I am posted to a remote PHC located 76 kilometers from the city of
Bangalore, where I stay. The PHC does not have any quarters and
there are no suitable houses available in the village for rent. 1 usu
ally leave home at about 6:30 in the morning and take a train for the
taluka town, which is 60 kilometers away. Thereafter I board a bus
and cover a distance of 26 kilometers to my PHC headquarters. It
takes about two and a half hours to reach my workplace. This PHC
does not have a jeep, and 1 do not have any other transport facility
to visit villages covered by the PHC. The PHC covers about 40 vil
lages, and the farthest village is located about 15 kilometers from
PHC headquarters. Thus 1 rarely step out of the PHC village. On a
190
. ifc >!-s ....
K
Constraints to Service Quality in Rural Karnataka
1
l!
few occasions I have requested my health inspector to take me to
some nearby villages in order to show at least a few outreach visits
in my records. The patient load at the PHC is very low, and most
people from the outlying villages [who need medical attention] go
either to the taluka headquarters or to private practitioners practic
ing in the roadside villages. I spend about two to three hours at the
PHC and leave for home in the afternoon immediately after lunch.
■<
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.
Ttes-
ASte
I
not available to them.
The following comment reflects the frustration felt by many ANMs:
-J®'’- ■
Ba
I H
Equipment and Supplies
..
pense them to their patients because drugs with active dates were
I
I cannot make visits to villages since I do not have any transport
and spend lot of time in traveling from my residence to [the] PHC.
frank. I have
havp not
nni visited
vicnori any
0™, village
------------>
To be frank,
covered1 by my PHC for
the past two years.
'J
J
191
refuse to accept the tablets, demanding other drugs for their illnesses.
Our informants also reported that although a large proportion of the
drugs they received had expired efficacy dates, they continued to dis-
I I.
b
Another participant medical officer also spoke candidly:
All the ANMs who participated in the group discussions reported an
acute shortage of dm VC Tn
Jagdish C. Bhatia
’t
C.
11
wa
Whenever people see us, they demand medicines, preferably injec
tions. If we say we do not have any, we are invariably accused of
not providing good service to the people and they get angry with
us. If we had an adequate and timely supply of required drugs, it
would greatly facilitate people's cooperation, and this would also
help us provide effective and efficient service to them. We spend a
great proportion of our time in the villages, and several villagers
come to us for treatment of minor ailments such as headache, cold,
cough, fever, etc. If we do not dispense drugs for these conditions,
they question the utility of our being there. How can we enlist their
cooperation in the implementation of various programs?
pressing problems they faced, telling us I
satisfaction and hindered not only their curative practice but also their
K
drmrs with money they receive from families for attending dehver. '■Ilaffc
drugs with
ies. Summing up the views of several participants, one ANM stated:
preventive, promotive, and family planning motivational work.
In principle, each subcenter has a budget for drugs. In 1994—95,
when this study was conducted, it was Rs5,000 per annum. ANMs
are also supposed to receive drugs needed for sterilized women who
are not able to reach the PHC or hospital for follow-up treatment. In
practice, however, the supplies of drugs that the ANMs receive are
inadequate to meet their requirements, and some of the drugs that
are made available are inappropriate or are past their expiration dates.
Moreover, according to our informants, the drug distribution system
at the PHC is haphazard. Whenever the ANMs need drugs they ap
proach the medical officer, who dispenses small quantities on an ad
hoc basis.
Some ANMs complained not only that they do
not receive
needed drugs in required amounts, but also that large quantities of
drugs they do not need are often dumped on them. Basic drugs such
fey
I k
KA?
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r= A'
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There was a consensus among LHVs who took part in the focus-group
discussions that to be effective, ANMs needed to receive essential
B
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as paracetamol and some analgesics, which are most needed, are ei
ther supplied in inadequate quantities or not supplied at all. Several
participants told us that they were given a huge quantity of folic acid
tablets and were compelled to dispense them to villagers for all ail
ments. The villagers have become aware of this practice and now
lust because we do not get drugs from the department,
we cannot
always tell our clients about our inability to treat them. After all, we
have to maintain a cordial relationship with people in order to carry
out our other tasks, such as family planning motivation and immu
nizations. In order to satisfy the people and enlist their cooperation
in other programs for which we have targets that must be achieved,
we have to provide them drugs and other treatment they require.
The drugs provided by the department will not last for even a few
months, and so we have to buy drugs from private medical shops
and dispense them to our patients.
r
K
drugs in a timely manner and in adequate quantities.
The medical officers who participated in the discussions con
firmed that the inadequate drug supply undermined their credibility
and seriously hampered the work of the PHCs and subcenters. Their
complaints included the following: (1) drugs are rarely supplied ac
cording to the medical officers' requisitions, which are based on the
morbidity pattern in their respective areas; (2) drugs that are not
needed are dumped on them, while lifesaving and essential drugs
ly^i
Constraints to Service Quality in Rural Karnataka
are supplied irregularly and in quantities far below actual require
ments; (3) some of the vaccines and drugs they receive have lost their
potency or are close to the date of expiration; (4) some drugs, pur
chased from local pharmaceutical companies, are of inferior quality;
(5) the PHCs do not receive cleaning agents, such as phenyl, needed
for keeping the premises clean and sterile; (6) equipment lies idle be
cause money is not available even for minor repairs; and (7) although
on paper each PHC has a budget of Rs30,000 for drugs, actual supply
is based on availability; on a first-come, first-served basis; and at the
whim of superior officers. As one medical officer stated:
My PHC has an annual budget of Rs30,000 for drugs. We normally
prepare an indent [requisition] for the required drugs, based on the
disease statistics of the PHC's area, and send it to the district office.
The government medical store is supposed to supply a portion of
the drugs indented, while the district health authorities are to sup
ply the balance. But we hardly ever get the drugs indented. The rea
sons for this are never explained to us. Irrespective of what we indi
cate in the indent, unnecessary drugs are dumped on us and we find
it difficult to use them. Sometimes one drug is supplied and the drug
complementary to it is not supplied; for example, penicillin is sup
plied but not the distilled-water ampules. We have often had to de
stroy the medicines because their shelf life has expired. Never dur
ing my 10 years' service have I received all the drugs listed in my
indent. The drugs are also of substandard quality, and we do not
get essential lifesaving drugs at all. Moreover, we have to pay the
suppliers Rs200—300 as a bribe to ensure that whatever drugs are
supplied are properly packed. If we do not pay, a proportion of the
drugs will be pilfered before reaching the PHC.
While being interviewed, a medical officer held up an ampule
of ephedrine and told the interviewer it was nearly 10 years old. Al
though it had lost its potency long ago, he was forced to use it be
cause fresh supplies of the drug were not available.
Another medical officer in a similar situation was more fortunate:
Sometime back I had to attend to an abnormal delivery. The woman
had a breech presentation. We did not have the correct scissors to
attempt an episiotomy. There was not even a single vial of
Methergine, which is used to arrest bleeding. There were no IV [in
travenous] fluids either, and there was no nursing or any other kind
of assistance available to me. I had to attend to the case single
handedly. The PHC is in a remote area, and the taluka hospital also
does not have any facilities to handle such cases. I conducted the de-
Jagdish C. Bhatia
I
livery with the resources available to me, and luckily everything went
well. If something [bad j had happened, I would have been blamed.
Transportation
■
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i'
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■
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1
The Department of Health and Family Welfare Services does not pro
vide transport facilities to enable the ANMs to carry out the tasks
assigned to them. This was a source of great dissatisfaction to almost
all the workers who participated in the focus-group discussions.
Nearly all those who work in the field have to cover several villages,
which are scattered, and in the absence of adequate transport, a sub
stantial amount of time is spent on travel. The ANMs have difficulty
carrying registers, equipment, drugs, and other materials they need
to their villages. Because many remote villages are not accessible by
public transport, the workers have to walk these distances, carrying
heavy loads. All ANMs expressed a need for an attendant who could
help them carry the materials to the villages. Currently the ANMs
are authorized to engage local help for this purpose and to pay an
attendant Rs50 per month, but this amount is so meager that no one
is willing to provide such help. As a consequence, the ANMs have to
carry the loads themselves.
This problem is felt acutely during the outreach immunization
program, when the ANMs have to carry a vaccine box and a pres
sure cooker in addition to their register, drugs, and contraceptive sup
plies. ANMs who walk with such heavy loads become exhausted and
are forced to cover only nearby villages. The remote villages thus do
not receive adequate attention from health workers. A case narrated
by an ANM vividly illustrates this problem:
I cover six villages with a total population of 3,015. This population
consists of 498 target couples, 138 eligible couples, 324 children in
the 1-4 year age group, and 81 infants. The farthest village under
my jurisdiction is situated 12 kilometers from the subcenter head
quarters, and it takes about 30 minutes to reach that village by bus. I
stay at the taluka town because there are no quarters at the subcenter
village and because it is difficult to rent suitable accommodation in
the village. I leave my house for work at 7:00 in the morning and
catch a bus. If I miss that bus, I have to wait for nearly two hours to
get the next bus. I very much feel the need for financial help from
the department to purchase a motorbike or motor scooter. This would
certainly be a great help in my work.
194
Constraints to Service Quality in Rural Karnataka
Some PHCs have vehicles in working condition that are some
times made available to ANMs for immunization outreach, and this
greatly facilitates their work. Without transport or an attendant, how
ever, several ANMs said that they were often forced to reduce the
frequency of their visits to remote villages or to drop those villages
from their rounds altogether. Having to rely on public transport,
which is infrequent and often irregular, forces ANMs to take bus
schedules into account when planning their field work. For example,
many health workers reported planning their immunization work
schedules to occur continuously for a week, generally the last week
of the month, during which period they did immunization work and
nothing else.
The difficulty of commuting to outlying areas caused one ANM
to seek a transfer:
I cover 11 villages having a total population of 6,504. In this popula
tion there are 885 target couples, 421 eligible couples, 123 children
in the 0-1 age group, and 442 children under five years of age. There
is no male worker or block extension educator in the PHC, and I
have to shoulder their responsibilities too. It takes about 15 minutes
to reach the farthest roadside village by bus, and from there I have
to walk to other villages within my area. I often get exhausted and
am unable to complete the work assigned to me. Such a heavy
workload and the absence of adequate transport facilities are ad
versely affecting my health and family relationships. I want to get
out of this situation and am therefore trying for a transfer and seri
ously looking for a person who could help me do this.
Jagdish C. Bhatia
as overseeing the school health program or Integrated Child Devel
opment Scheme (ICDS) activities, due to the nonavailability of offi
cial transport. One medical officer vividly described these problems:
II
I
■©
ii
I
■;
All ANMs suggested that this problem would be greatly eased
if the department were to issue them motorcycles. The vehicles would
improve their efficiency and result in a substantial improvement in
the coverage and quality of care.
The LHVs also have to cover large areas to supervise the work
of the ANMs. In addition, they are required to visit the angcmwadi
(preschool) centers in their district to provide support and guidance
to anganwadi workers. In the absence of official transport or a reli
able public transport system, their supervising responsibilities are of
ten neglected. Several of them suggested that their mobility would
be improved if transport facilities were provided.
Likewise, medical officers are prevented from making scheduled
visits to the subcenters or performing their other responsibilities, such
195
it
I
I cover a population of about 32,000. We do not have any official
transport at our PHC. ... At my PHC I also spend lot of time on
attending to patients, postmortems, and medico-legal cases. I am
therefore not able to follow the advanced tour program of visiting
the subcenters and other villages covered by my PI 1C. The unavail
ability of official transport makes these visits difficult, or rather im
possible. I can review the work of my staff only at the monthly con
ference, which is held at the PHC on the last working day of every
month. During these meetings I discuss the performance of each
worker in terms of targets assigned and achieved, and give appro
priate instructions. I mostly leave the general supervision of AN Ms
to the LHVs, who are asked to report to me on a regular basis about
the problem workers and those who lag behind in their work. In
cases where there are serious complaints from the community about
a worker, 1 try to visit the village and inquire from the villagers about
the problems and then take action to remedy the situation. This, how
ever, happens only once in a while. ... Let me be frank. It is just not
possible for me to visit the villages without adequate transport facility.
I know that supervision work suffers due to this. But what can 1 do?
The delivery of health and family welfare services at the PHC is fur
ther hindered by several vacant staff positions. Almost all medical
officers mentioned that it was very difficult to provide adequate cov
erage or improve the quality of services without a full complement
of sanctioned staff. Even when all positions are filled, fieldworkers
are overburdened. Having vacant positions worsens the situation.
According to one medical officer;
1 KU
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I cover a population of 38,000, spread out in 80 villages. There are
eight subcenters under the PHC. Though all the ANM positions are
filled, there is not even a single male worker in the entire PHC area.
The position of LHV has also been vacant for quite some time. The
senior health inspector is responsible for supervising the work of
the ANMs; but because I do not stay at the PHC, he is more inter
ested in practicing medicine, mainly in the PHC village, rather than
providing supervision and guidance to ANMs. Thus the ANMs are
left on their own and hardly receive any support and guidance in
their work.
196
1
Constraints to Service Quality in Rural Karnataka
All medical officers reported making several personal, as well
as formal written, requests to the higher authorities for personnel to
fill the vacant positions, but to no effect. Another problem that our
informants repeatedly mentioned was that of "punitive" or "stopgap"
I
J
■ - ^3
I
I
postings due to political interference. The personnel posted in this
fashion are hardly motivated to do any work and instead are a nega
tive influence on those who are performing satisfactorily. A medical
officer described the effect of this as follows:
I have recently been posted to the present PHC. My predecessor had a
lot of problems with the people, and with the interference of the health
minister he was transferred to another PHC. I hear that he is idling away
his time there and is not doing anything worthwhile. The clerk at this
PHC who is supposed to assist me in administrative work has been
sent here by the director on a "punishment" transfer. He does not lis
ten to me and behaves insultingly toward the other staff members. The
LHV too is on a punishment transfer. She stays in Bangalore and nei
ther comes to the PHC regularly nor visits the subcenters. These per
sons have been with the department for several years and are not ame
nable to any discipline. What can I do in this situation?
•I
i
■
1I
1
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i
I
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Another participant observed:
I cover a population of 37,000. In my PHC the post of pharmacist
has been vacant for the past two years, that of block health educator
for one year, three male workers' posts have been vacant for a long
time, and there has been no laboratory technician for quite some time.
I rely upon the assistance of the ANM at headquarters to dispense
medicines and do other office work. The blood slides are sent to the
taluka hospital for examination. All this disrupts the work routines.
Whenever there is a vacancy at a subcenter, the ANM from the
adjoining center has to cover that area. This adversely affects her per
formance. Moreover, the vacancy of an LHV position makes the situa
tion worse because all ANMs in the PHC remain unsupervised. Most
medical officers who participated in the discussion considered this
problem to be very serious.
In addition to chronic staffing vacancies, the ineffective and in
efficient utilization of available manpower adversely affects the cov
erage and quality of health and family planning services. This con
clusion is based on the continuous observation of selected providers
over a period of approximately 45 working days. The following time
utilization patterns emerged from the observations.
life
I
•B-
■I
Jagdish C. Bhatia
ANMs. Seven ANMs were observed. Each observation started
when the ANM began her workday and ended when she announced
she had finished her day's work. Throughout this period a female
observer accompanied her wherever she went. A total of 249 ANMdays were observed, and the average duration of work for each ANM
was 247 minutes per day. The seven ANMs spent approximately 65
percent of that time providing services, 19 percent on travel, and about
16 percent on personal activities (Table 10.1). Thus the ANMs' average workday was only slightly more than 4 hours long, and their ef
fective working time averaged under 3 hours. 'Ihat is hardly enough
time to provide good coverage and quality services to the population
served by a subcenter (see also Koblinsky et al. 1989).
LHVs. The study team observed one LHV for 45 working days.
Her average workday was slightly less than 4 hours (236 minutes).
“ ’ j an average day she spent 160 minutes, or 68 percent of her
During
time, on productive activities; 27 minutes, or 11 percent of the total
time observed, on travel; and 49 minutes, or 21 percent of her time,
1
on personal work or activities (Table 10.2).
Also shown in Table 10.2 is a more detailed breakdown of how
the LHV's service-related time was spent. Although a major respon
sibility of LHVs is to provide supervision and guidance to ANMs,
our data indicate that the LHV spent an average of only 41 minutes a
day, or 26 percent of her total productive time, on supervisory work.
Other activities that consumed a sizable proportion of her produc
tive time were maintaining records (16 percent), office work (12 per
cent), and Child Survival and Safe Motherhood (CSSM) training (11
percent). Meetings at district headquarters, ICDS work, and interac
tion with workers also received a share of her attention.
Medical officers. Charged with overall management of the PHC
included in the observation study was an administrative medical of
ficer. The PHC had two other medical officers, a male and a female.
During the absence of the administrative medical officer, the male medi
cal officer assumed management responsibility. In the event that both
of those medical officers were absent, the responsibility for day-to-day
operations of the PHC was entrusted to the female medical officer.
To assess the work pattern and the time utilization of the three
medical officers, the observation team adopted a work-sampling
method. The work of the medical officers was sampled about three
198
Constraints to Service Quality in Rural Karnataka
TABLE 10.1
Time utilization pattern of ANMs at a rural PHC:
Kolar District, Karnataka, 1994-95
TABLE 10.3
Observed activities of medical officers at a rural PHO:
Kolar District, Karnataka, 1994-95
Activity
Average number
of minutes spent
per ANM per day
Percentage of
total work time
spent per day
Service
Travel
161
47
65
Personal
39
247
16
All activities
(No. of ANMs observed)
(No. of ANM-days observed)
Percentage of time,
by type of medical officer
3
I
I
19
100
Service/productive
Supervision
Record maintenance
Office work
CSSM training
Meeting at district headquarters
ICDS work
Interaction with workers
Participation in camps
Other
Travel
Personal
All activities
1
Percentage of
total work time
spent per day
160
41
25
19
18
15
12
11
11
8
27
49
236
(No. of LHV-days observed)
Attending to patients
Interacting with other medical officers
Away on official work
Personal work
TABLE 10.2
Time utilization pattern of an LHV at a rural PHC:
Kolar District, Karnataka, 1994-95
Average number
of minutes spent
per day
Activity
Administrative
medical
officer
Male
medical
officer
Female
medical
officer
36
36
30
2
4
44
10
2
4
4
6
28
2
4
2
2
Interacting with others
(7)
(249)
ANM=auxiliary nurse-midwife; PHC=public health center.
Activity
199
Jagdish C. Bhatia
68
26
•1
|
12
11
11
i
I
■1
'
■■
21
100
(45)
I
Scheme; LHV-lady health visitor; PHC=primary health center.
days a week, or 25 days during the entire observation period. In all, there
were about 50 rounds of observation for each of the three medical offi
cers. Their activities during those rounds are summarized in Table 10.3.
In addition to being in charge of the PHC, the administrative
medical officer included in the study looked after another PHC in
the subdistrict. He therefore had to spend considerable time travel
ing from one PHC to the other. He was trained in conducting tubec
tomies and was deputized by his superiors to several tubectomy
Conducting tubectomy at PHC
Resting
Not yet arrived at PHC
I
16
9
8
7
7
5
I
Attending meeting at PHC
Administration
I'
R-.
Just arrived at PHC
Absent or on leave
Other
(No. of workdays sampled)
(No. of observations)
8
2
(25)
(50)
34
6
2
12
(25)
(50)
2
34
8
2
16
2
(25)
(50)
PHC=primary health center
camps in other PHCs to perform sterilization operations. Because he
had received CSSM training, he was also asked by his superiors to
provide similar training for LHVs and ANMs at the subdistrict head
quarters. He was therefore absent from his PHC on official duty dur
ing 44 percent of the observation period, and was absent on personal
work for another 10 percent of the time. This medical officer was ob
served attending to patients or conducting tubectomies for 40 per
cent of the time. Thus he spent less than 10 percent of the observa
tion time on the management of the PHC, which was one of his
primary responsibilities. The other two medical officers attended to
patients between 30 and 36 percent of the observation rounds and
were observed not to be engaged in any official duty during 34 per
cent of the rounds. These medical officers spent little or no time on
activities related to overall administration or management of the PHC,
even during the absence of the administrative medical officer.
Several medical officers who participated in our discussions had
postgraduate qualifications and specialist training. Those specialists
200
Constraints to Service Quality in Rural Karnataka
■ fe-
were posted to PHCs where facilities to practice their specializations
do not exist. While the specialist positions at community health cen
ters and taluka hospitals remain vacant, a large number of specialists
are posted to lower-level institutions. A female medical officer with
specialist training in obstetrics/gynecology made the following comments during the discussions:
health problems, community organization, and treatment of common
illnesses. Several LHVs said they would be interested in receiving
advanced training, especially in community organization and cura
'W' •
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I am posted to a remote PHC where there are no facilities whatso
ever for conducting even normal deliveries. I can never handle ob
stetric emergencies or complicated deliveries here. The outpatient
department has about 80 cases a day, the majority of them women
and children. However, for most of the gynecological problems and
obstetric complications, women go to taluka headquarters and con
sult a private gynecologist/obstetrician. Ironically, while I am rot
ting at the remote PHC, the taluka hospital does not have a quali
fied gynecologist. Furthermore, my PHC is not well connected to all
the villagers in my jurisdiction. The people therefore prefer private
doctors at the taluka headquarters.
IB
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An anesthesiologist stated that because he had been working in
various PHCs for more than 10 years, he had lost touch with his area
of specialization. Despite the existence of vacancies for anesthetists
in several hospitals in the state, he had not been posted there. A simi
lar account was given by a specialist in ears, nose, and throat. Most
of the participants blamed corruption and nepotism for this problem.
They charged that specialists who could pull strings with politicians
and influential persons were posted to major hospitals in the cities
and towns, whereas others had to waste their talents and expertise at
rural primary health units.
I k
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Training
The type of training received by providers determines their profi
ciency and technical competence, which in turn affect the quality of
services. Several workers reported that they were performing tasks
for which they had not been adequately trained. When asked if they
needed further training to improve the efficiency of their work, an
overwhelming majority of the ANMs answered in the affirmative. The
aspects in which they wanted to improve their competence were mo
tivational aspects of family planning, insertion of intrauterine devices
(IUDs), diagnosis and treatment of gynecological and reproductive
Jagdish C. Bhatia
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tive aspects of health care.
In order to diagnose management problems, a questionnaire was
administered to all the medical officers who participated in the focus-group discussions. The completed questionnaires revealed that
most of the medical officers lacked capabilities in planning, supervi
sion, direction, organization, and evaluation. Thus a need clearly ex
ists for management training for the medical officers.
Supervision
The technical competence and performance of workers also depends
upon the type of support and guidance they receive from their su
pervisors. ANMs are supervised by LHVs, who are supposed to make
regular field visits and observe the quantity and quality of services
delivered by them. An LHV supervises on average the work of six
ANMs. During the focus-group discussions the ANMs reported that
the LHV visited them in the field two or three times per month. Al
though the supervisory styles of LHVs varied considerably, almost
all the ANMs perceived that the supervisory efforts of LHVs were
directed mainly toward seeing that the ANMs achieved the targets
assigned to them. Some of the ANMs mentioned that their supervisors
were not interested in their problems or the quality of services. As one
participant noted:
The HV sister [a respectful way of addressing an immediate female
superior] does not bother about how 1 carry out my activities so long
as I complete my targets. If I talk about any field problems with her,
the stock reply is: "Don't tell me all these things. You are supposed
to achieve these targets. Have you done this? I am not interested
about knowing how you do this—whom you contact and the like.
What I want are results. Just deliver them and I will never bother
you. If you don't, then I am not responsible for whatever happens."
Almost all the participants reported receiving little guidance from
the medical officers, except during the monthly meetings, when the
medical officers reprimanded them for not achieving their targets. In
addition, the medical officers seldom visited them in the field. The
202
Constraints to Service Quality in Rural Karnataka
discussions revealed that although a majority of the ANMs appeared
to discharge their duties conscientiously, the lack of close supervi
sion by medical officers encouraged complacency, and many tended
to visit outlying villages for only short periods—say, an hour—to meet
their tour requirements.
The assessment of the amount of work performed by an ANM is
usually based on the number of pregnant women she registers (three
per 1,000 population a month is the norm), the number of antenatal
visits she makes, and the number of blood slides she collects. Ques
tions about the quality of MCH and other care she provides are rarely
asked. For example, there is no mechanism for checking whether
blood slides are actually collected from clients reporting fever or
whether more than one slide is collected from the same person.
The LHVs who participated in the focus-group discussions re
ported that the medical officers never accompanied them on field vis
its. They also cited numerous instances in which the medical officers
had not acted on LHVs' complaints about ANMs who, despite re
peated warnings, showed no improvement. By not taking appropri
ate action (e.g., by issuing written warnings or show-cause notices)
the medical officers caused LHVs embarrassment. The LHVs also com
plained that the medical officers showed no concern about the qual
ity of services.
The LHVs offered a number of suggestions for making their own
supervision more effective. Those suggestions included (1) improv
ing the LHVs' mobility by providing transport facilities; (2) reducing
the number of ANMs to be supervised by each LHV to about four,
with a total population of roughly 20,000; (3) providing loans at sub
sidized interest rates to LHVs for the purchase of motorcycles; (4)
avoiding frequent transfers of LHVs by retaining them in an area for
at least four to five years; and (5) providing incentives to good work
ers by instituting rewards, and giving the rewards on the recommen
dation of the LHVs.
The medical officers described various mechanisms—such as
monthly meetings, perusal of reports, routine and surprise visits—that
they use for overseeing the work of their subordinates. However, the
medical officers rarely visit the subcenters and outlying villages. They
gave several reasons for their inability to undertake such visits on a
regular basis. First, they have to spend most of their time at the PHC
Jagdish C. Bhatia
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203
outpatient department, seeing patients. If they fail to discharge their
curative responsibilities, community members lodge complaints against
them and bring political pressure to bear for their transfer. The villag
ers, according to them, are least interested in other preventive and pro
motive services. Other duties (postmortems, medico-legal cases, and
general administrative work) leave them little time for outreach visits.
Second, many PHCs do not have official jeeps for making field inspec
tions. Vehicles in working condition are shared by many PHCs for im
munization and family planning work. For these reasons the medical
officers are not able to supervise all the PHC staff and must concen
trate their efforts on those who are not able to achieve their targets.
Although an overwhelming majority of the medical officers we
interviewed were not making field visits, there were a few exceptions.
Several reported using their personal vehicles to visit subcenters near
the PHC:
My PHC covers a total population of 26,000 with nine subcenters.
Almost all the ANMs stay in Bangalore and commute daily to their
workplaces. There is no vehicle in our PHC, so I use my personal
scooter to visit villages.
A female medical officer told us that she spent about four days
per month supervising workers in the field:
I normally make surprise visits. During my visits I find that about
half the ANMs in my PHC do not make visits as per their advanced
tour program. When 1 visit the village 1 usually contact the women
in the household and inquire about the worker. 1 check the stencils
on the wall [the workers are supposed to record the dates of their
visits to the household on the stencil]. I also visit a few pregnant
women and ask them about their antenatal checkup by the ANM.
Whenever I receive complaints, 1 personally warn the concerned
worker, and in some rare cases in which the worker continues to be
insolent I report her behavior to the assistant district health officer.
All the medical officers remarked on the difficulty of motivat
ing male workers to fulfill their duties. If the medical officers inquired
about their activities, the male workers misbehaved and complained
about the medical officers to their superiors. Because those workers
are largely a nuisance, the medical officers ignore them.
As far as supervision of the medical officers by their superiors is
concerned, although the assistant district health officer and district
204
Constraints to Service Quality in Rural Karnataka
health officer are supposed to visit the PHCs on a regular basis, such
visits are rare and occur only during emergency situations, such as
epidemics, or for inquiries into specific cases, such as maternal deaths.
By and large, the performance of the medical officers is assessed dur
ing monthly meetings at the district headquarters.
F
to reduce the quality of sterilization services, as illustrated by the fol
1I
lowing incident related by a medical officer:
Yesterday I conducted a total of 44 tubectomies at a camp about 10
kilometers from our hospital. Can you imagine that during the en
tire duration of operations there was no electricity? Women who had
been brought from distant villages by our staff had to wait for hours
at the campsite. There was a complete blackout in the entire camp
area, and in the makeshift operation theater a nurse held a flash
light overhead for five hours while 1 operated. Many times I shud
dered at the prospect of mistakenly cutting a urethra or some other
organ because I could not see very clearly what I was incising. But
to whom do I tell all this? We have to somehow do these operations
and achieve the targets, you see. That is an order from above. 1 am
often amazed at the way tubectomized patients recover from com
plications, such as sepsis, that might have been due to our lack of
drugs or even to errors during surgery. How long will I continue
doing this against my conscience?
Family Planning Targets
Workers are assigned targets for the acceptance of specific contra
ceptive methods. Those who participated in the discussions, irrespec
tive of their level, were not sure what the basis was for these targets—
whether it was the total population or the number of eligible couples
in the catchment area of a subcenter. Workers voiced divergent views
about the desirability of having targets. Most ANMs were opposed
to targets. However, most supervisory personnel (LHVs and medical
officers) felt that targets were essential for good performance, as they
kept the workers on their toes.
The focus of review meetings is the achievement of targets. Fifty
percent of all targets are now reserved for spacing methods. The
achievement of those targets is judged by the number of condoms or
cycles of oral pills distributed, not by the number of couple-months
of protection. Workers often give an inflated account of their achieve
ments, and it is difficult to find out whether the contraceptives have
actually been distributed or used. According to the LHVs and medi
cal officers, ANMs concentrate mainly on female sterilization because
-
most women are favorably disposed toward tubectomy, saying that
they want to have two children and then be sterilized. Given this pref
erence, the achieved targets reported by the workers for spacing meth
ods are probably greatly exaggerated.
With the Family Welfare Programme's primary emphasis upon fe
male sterilization, little attempt was made by the workers to motivate
males for vasectomy. However, in recent months the Department of
Health and Family Welfare Services has issued directives to recruit cases
for vasectomy. The supervisory staff are therefore insisting that each
ANM should motivate at least one person for vasectomy each month.
Most of the LHVs felt that targets should be determined on the
basis of remaining eligible couples, not on the basis of total popula
tion. In an area where most couples are already protected from un
wanted pregnancies, it is difficult to achieve targets. Targets also tend
Jagdish C. Bhatia
Incentives in the form of cash payments are still offered to those
undergoing sterilization. These incentives are in kind and cash and
are periodically revised. Even though the PHCs have adequate bud
gets for paying the incentives, several participants mentioned that
some of the money was withheld by hospital staff and the balance
was taken by the patients' husbands. In fact, the women undergoing
sterilization do not receive any money. The ANMs receive no mon
etary reward when they succeed in motivating acceptors, but those
who motivate the largest number of acceptors receive recognition by
having their names published in the departmental newsletter.
Corruption
i
h
During the in-depth interviews and focus-group discussions, all cat
egories of workers cited the issue of widespread corruption. The
ANMs complained that their travel bills, arrears, and other claims were
inordinately delayed unless they agreed to pay a portion of their claims
as "speed money." A medical officer made the following comment:
There is corruption at all levels in our department. We have to bribe
at each and every stage, from clerk to higher officers, to get our sal
ary and other claims passed. We are not supplied with stationery or
registers and have to purchase them locally, spending from our own
pockets. The expenditures incurred by us are never reimbursed.
*
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206
Constraints to Service Quality in Rural Karnataka
Jagdish C. Bhatia
Similarly, an LHV with more than two decades of experience recounted:
In the past, although we had much less manpower, logistic support
service prerequisites, housing, etc., you will be surprised to learn
that we used to work well. The main reasons for this are that there
was a high level of motivation to work due to much less corruption,
dedicated workers and officers, and proper material handling and
accounting. Family planning targets were strictly adhered to, and
efforts were made to promote all types of contraceptive methods,
such as cervical caps [diaphragms], jelly/cream, oral pills. Gold Coin
[condoms], IUDs, and sterilization. Though people had apprehen
sions about family planning, the health staff used to convince them
to accept it and motivated them with so much zeal so that I remem
ber people used to drop into our office and inquire about some
method or the other and even advise others to have small families.
However, over time the working standards deteriorated with
the gradual erosion in the ethical standards of immediate supervi
sors and higher officials, which paved the way to the institutional
ization of corruption affecting the Health Department. Today, to be
corrupt is no longer considered reprehensible. Drugs and equipment
in the health facilities are misused without any hesitation. The doc
tors are interested only in private practice and amassing wealth.
Charging poor villagers money for services at the PHC is no more a
taboo. The nexus between government doctors, drugstores, private
practitioners, and other top officials is very strong. In this situation
people have lost confidence in the government health care system
As a consequence, influential people in the rural areas have devel
oped an aversion toward the health staff and hence avoid them. On
their part, the health workers, in order to achieve their targets, prom
ise impossible things and even spend money from their pockets to
woo their clients for sterilization. No sooner is the client sterilized
then the worker leaves her at her mercy and looks for another case
for sterilization.
4
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207
The quality of health and family planning services depends to a
large extent upon the technical competency and motivation levels of
their work force. These are in turn determined by how skillfully this
human resource is managed and supported. This study, which has
focused upon the perceptions and experience of grassroots and clini
cal health care providers in rural Karnataka, has highlighted a range
of operational barriers that constrain the provision of high-quality
services within the public sector. The analysis indicates that not only
is there a shortage of key staff, but that existing staff are not opti
mally utilized. A primary contributing factor is low morale, a conse
quence of the inadequate availability of staff housing, drugs, equip
ment and supplies, and transportation, as well as lack of supervision
and support from senior staff. A further contributing factor is wide
spread corruption in the department, which deters improvements in
the coverage and quality of care.
The discussions revealed that although some ANMs found their
job of providing health care to populations in need rewarding, many
others were dissatisfied. Even those ANMs who were generally posi
tive about their work felt frustrated at times because of the problems
they faced. A primary indicator of low morale was the fact that a ma
jority regretted having joined the governmental health sector. Many
of the same problems mentioned by the ANMs were also found to be
major sources of frustration among the LHVs and medical officers.
Many staff believed that their abysmal working conditions prevented
them from delivering their services in an effective and efficient manner.
The following statement by an ANM perhaps most aptly sum
marizes the constraints that clients and grassroots service providers
face, respectively, in seeking and providing a high quality of services
within the public sector's primary health system:
Discussion
Several studies have shown that an overwhelming majority of people
use private sources of curative health care, and are willing to pay for
the services rather than seek care available from government health
facilities, which remain underutilized. A principal reason is the poor
quality of care provided in much of the public sector. As a first step
toward addressing this issue, it is important to identify the specific
factors that contribute to the poor quality of services.
I
I joined the department about three years ago and have been work
ing in this area since then. During this period I have come to under
stand most of the problems of the people in my area. I find that the
people, though poor, are nice. Their health needs are very basic. But
we are unable to satisfy the needs of the people even in the villages
I cover. I treat minor ailments such as headache, fever, and the like,
and provide them with a few basic drugs. But the drug supply is
utterly inadequate. Basic drugs such as chloroquine, paracetamol,
and some analgesics are not available to me. With no medicines at
hand, I have no recourse but to refer the patients to the PHC.
Constraints to Service Quality in Rural Karnataka
L:
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fe . Dutt, P.R. 1965. Rural Health Services in India: Primary Health Centres, 2nd ed. New
At the PHC, the story is no different. The patients who go there
return complaining that they were not treated well and had a very
can Te7 7rwngCe7ithKthe Staff memberS there- In this si‘uation wh7t
can I do What authority do I have to advise them on health and
family Planmng matters? Even if I try to motivate couples to use
family plannmg methods, they will not listen to me and I lose my
credibility among the community. I feel sad to say that almost all
ILI!!a
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Acknowledgments
I am extremely grateful to Dr. N. S. N. Rao and Mr. N. S. Sanath
m •
valuable assistance in moderating the discussions and for skillfully transcribing
lected^taTom th"85 3nd ,translaJinS them into English. Mr. Kumar also col
lected data from the providers under the Dynamics of Contraceptive Use Stud v
Study,
an’d’d-r5 W^h.1S lncluded ln ‘his chapter. I am also grateful for the Use
intelligent
and diligent data processing and analysis by Mr. S. Ramaswamy.
8
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References
'.'l
BabTm?l' P'Klfand RaVi K' Verma' 1991' "J°b satlsfaction among health and
fami y welfare personnel: A case study of two primary health centres in
Kerala, Journal of Family Welfare 37(2): 14-23.
4
and ab°rtiOn SeekerS'"Indian ,0“rnal °fSocial Work
.
d.,M:
Chuttani, C.S., J.C. Bhatia, Dharamvir, and A. Timmappaya. 1973. "A survey of
indigenous medical practitioners in five different states in India " j J
Journal of Medical Research 61 (6): 962-967.
' ndian
. 1976. "Factors responsible for underutilization of primary health centres^ A
community survey in three states of India," NIHAE BulleM(3)-. 229-277.
* uni
unpublished report. Survey Research and Training Centre, New Delhi.
; Indian Council of Medical Research (ICMR). 1991. Evaluation of Quality of Family
Welfare Services at Primary Health Centre Level: An ICMR Task Force Study.
New Delhi: ICMR.
Jesani, Amar. 1990. "Limits of empowerment: Women in rural health care," Leo
Ift
?
nomicand Political Weekly 25(20): 1098-1103.
ft • - Johns Hopkins University, Department of International Health. 1976. Functional
Analysis of Health Heeds and Services. New York: Asia Publishing House.
RL Kanitkar, T. and R.K. Sinha. 1989. "Antenatal care service in five states of India," in Population Transition in India, vol. 2, eds. S.N. Singh, M.K. Premi,
■'1 k
---<1
■I
.
P.S. Bhatia, and Ashish Bose. Delhi: B.R. Publishing.
Khan, M.E. 1989. "Access to family planning services in rural Uttar Pradesh,"
4 ff?-Journa
l °f
Journal
ofTamily
FamilyWelfare
Welfare35(3):
35(3):3-20.
3-20.
E Koblinsky, M., S.J. Griffey Brechin, S.D. Clark, and M.Y. Hasan. 1989. "1 lelping
managers to manage: Work schedules of field-workers in rural Bangladesh,"
.'
Studies in Family Planning 20(4): 225-234.
■ Kk
Misra, B.D., G.B. Simmons, A. Ashraf, and R. Simmons. 1982. Organization for
Change: A Systems Analysis of Family Planning in Rural India. Ann Arbor:
University of Michigan Center for South and Southeast Asian Studies.
Narayana, G. and P.H. Reddy. 1980. "Organizational problems and levels of job
satisfaction of primary health centre personnel," Indian Journal of Social Work
41(1): 11-20.
7? '
Neumann, A.K. and J.C. Bhatia. 1973. "Family planning and indigenous medi
cine practitioners," Social Science and Medicine 7:507-514.
| Neumann, A.K., J.C. Bhatia, S. Andrew, and A.K.S. Murthy. 1971. "Role of indigenous medical practitioners: Report of a study," Social Science and Medi
cine 5:137-149.
•‘.sis
■ kPaliwal, M.B. and N. Sawhney. 1982. "Job satisfaction measuring scale for fam
ily welfare personnel," unpublished report, Population Centre, Lucknow.
■■ E?
Parker, R.L., A.K.S. Murthy, and J.C. Bhatia. 1972. "Relating health services to com
munity health needs," Indian Journal of Medical Research 60(12): 1835-1848.
j k
Ramachandran, L. 1989. "The effect of antenatal and natal services on pregnancy
outcome, and health of the mother and the child," Journal of Family Welfare
35(5): 34-46.
Rastogi, S.R. 1978. "Study of family planning workers in Uttar Pradesh, unna Cpntre
published T-or-»r-»r4report. Oomocrrar»hir
Demographic Traini
Training
Centre, Lucknow.
Lucknow.
Ray, Amal. 1976. Organizational Aspects of Rural Development. Calcutta: World Press.
Satia, J.K. 1976. "Family planning workers and problems of program implemen
tation," Economic and Political Weekly 11(38): 1547-1552.
Shariff, Abusaleh and Pravin Visaria. 1991. Family Planning Program in Gujarat:
A Qualitative Assessment of Inputs and Impact. Ahmedabad: Gujarat Insti
tute of Area Planning.
Udupa, K.N. 1991. A Final Report of Operations Research of Primary Health Care in
Varanasi District. Varanasi: Institute of Medical Sciences, Banaras Hindu
University.
J
isl d fS
PaSS the bUCk' and ultima‘ely I am admon
ished for the laults of others.
”»• S'“"“ “ s“"
’ ’ diandian Institute of Management.
Gupta, V<reera et al. 1987. "Job satisfaction: A study of primary health centres,"
.;-W>
eir respect. If I approach my superiors with my problems I am
repnmanded and threatened with disciplinary action. So I suffer siently. My superiors are not at all bothered by my predicament. When
Bhatia, J.C., Dharamvir, C.S. Chuttani, and A. Timmappaya. 1975. "Traditional
Bhatia TCDh modern™dicine/' Social Science and Medicine 9:15-21
a'rJ/S;DharamfVlr'> T,mmaPPaya' and C.S. Chuttani. 1974. "The role of
practitioners of indigenous medicine in the family planning program- A
study in three states," Journal of Family Welfare 20(3)- 18-27 8 ? 8
Delhi: Central Health Education Bureau.
Ghosh, B. 1992. Time Utilization of Primary Health Care Workers. Bangalore: In-
i
at thePHC 7 We7 referred by me haVe had the Same experience
at the PHC. I urgently need an adequate supply of drugs because I
cannot just talk with people, but must do something practicalto elm
BHati34(J:'
Jagdish C. Bhatia
J HL
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qualifications (WHO 1961, p. 4). India's Second Five-Year Plan de
scribed the role of auxiliary health workers as supplementing the contributions made by doctors and other highly trained personnel for
promoting preventive and curative health activities (GOI, Planning
Commission 1956, p. 540). In their capacity as technicians, vaccina
tors, and assistant midwives, auxiliary workers support both the medi
cal and the nursing professions. Therefore, auxiliary workers derive
their legitimacy from their interactive relationship with profession
ally trained personnel, and they derive their effectiveness from the
network of physical and professional support structures to which they
belong.
The role of ANMs in India has changed markedly over the past
four decades. ANMs were initially seen as assistants to midwives in
maternal and child health (MCH) centers. All of this changed during
the 1960s and 1970s. Family planning was integrated with MCH ac
tivities and projected as a program deserving the highest priority
(GOI, Planning Commission 1968). The committee appointed to re
view the staffing pattern and financial provision of the Family Plan
ning Programme, now called the Family Welfare Programme, recom
mended a system of targets and incentives and identified ANMs and
other village-level workers as agents for the popularization of the pro
gram (Mukherjee Committee 1966).
Further discussions on integrating the functions of the primary
health centers (PHCs) and of village-level health workers led to the
formation of a full-fledged Committee on Multipurpose Workers in
1972 at the initiative of the Executive Committee of the Central Fam
ily Planning Council. The committee transformed ANMs and the host
of malaria workers into multipurpose workers (MPWs). ANMs wen*
now required to provide child health services and primary curative
care to villagers. Thus ANMs have long ceased to play the peripheral
role conceived for them at the time of national independence. Their
heightened accountability and increasing visibility in the community
have transformed them into key workers at the interface of health
services and the community. The realization of this potential, how
ever, is dependent upon support systems such as preparatory train
ing, ongoing professional and interpersonal support, facilities, and
equipment. This chapter reviews and evaluates the adequacy and
quality of these systems.
...
11 Barriers to the Quality of Care:
:
b"
The Experience of Auxiliary
Nurse-Midwives
in Rural Maharashtra
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ADITI IYER & AMAR JESANI
F
The notion of quality in the public health s
ystem is becoming increasingly an issue for policymakers and planners in India. The Eighth
Five-Year Plan identified the poor quality of family welfare services
as one of the factors hindering the achievement of a lower birth rate
(GOI, Planning Commission 1992, p. 333). More recently, the Indian
government has outlined elements of a quality-oriented, or qualityfocused, approach in the Reproductive and Child Health Programme
(GOI, MOHFW 1996).
6
As a concept, quality is attuned to the needs and satisfaction of
the users of health services. By that token, a quality approach lends
itself easily to the fulfillment of desired outcomes, whether these are
measured by better health status or improved demographic indica
tors Such a result is possible only when quality efforts are sufficiently
backed up by adequate and rationally distributed infrastructure and
material resources. The relationship between quantity and quality is
nest expressed at the ground level. This chapter reflects these ground
rea ities from the perspective of auxiliary nurse-midwives (ANMs)
in Maharashtra.
ANMs are auxiliary workers employed by the district adminis
tration to occupy the lowest rung of the public health bureaucracy.
The World Health Organization has broadly defined auxiliary work
ers as technical workers in a particular field who have less than full
210
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Aditi Iyer • Amar Jesani
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.kUAHiary Nurse-Midwives in Rural Maharashtra
According to national norms, a PHC should serve a population
numbering 30,000 under the leadership of a medical officer (doctor).
Even if a PHC has two medical officers, it still has only one doctor
for 15,000 people. In view of the demands of their work, these doc
tors are hardly in a position to provide constant supervision to ANMs
and male health workers posted at the subcenters. The problem is
exacerbated by vacancies in the post of medical officer. This absence
of a team leader effectively forces the ANMs to carry out the day-today work of the subcenter in an independent fashion. Thus, contrary
to their status as auxiliaries, ANMs become de facto independent work
ers—quasi doctors—with neither the recognition nor the wherewithal
necessary to play such a role in the health service and the community.
The situation of ANMs is rendered more complex because it in
corporates a social dimension. Although both ANMs and male worka ntw01? Under tHe jurisdictiQn of the district health administration,
ANMs have several inherent disadvantages. First, although they are
registered with the Nursing Council and their affiliation with the nurs
ing profession provides them with a better legal status than male
workers (who are unregistered), ANMs are only paraprofessionals
by training. Therefore they do not enjoy the same status as fully
trained nurses and find themselves marginalized within the council.
Second, the cadre of ANMs is composed exclusively of women, un
like the nursing profession, which allows the participation of males
however marginal that participation might be (in 1990, only 4 percent of nurses registered with the Maharashtra Nursing Council were
men). The inequalities rooted in ANMs' gender thus add another di
mension to their subordinate status. Their affiliation to nursing car
ries a negative social image, in view of the specific requirements of
t leir work. ANMs bear the additional burden of a reputation—a ster
eotype—that portrays them as immoral women, and this represents a
major handicap when they work with rural communities (Jesani 1990)
The gender differential is also manifested in a division of labor
between male and female workers. Whereas male workers are ex
pected to assume an active role in controlling malaria, tuberculosis
othec communicable diseases, ANMs are principally responsible
for MCH activities. One reason for this division of labor is undoubt
edly the carryover effect of their previous functions. Its outcome,
which draws its ultimate justification from
the "natural functions"
argument, is striking. On the one hand, the sex of the male health
I
Aditi Iyer • Amar Jesani
2Lj
worker and his use of laboratory slides and other "clinical" devices
conspire to project his image in the community as a malaria "doctor"
(Jesani 1990); on the other hand, the female worker is regarded merely
*
as a "nurse bai" (bai being a common form of addressing women in the
area). The difference is not merely a matter of semantics; the associa
• -W.tions suggest that the male worker is more competent than his female
jh.- counterpart.
In addition, unlike her male counterpart, an ANM is expected
to maintain the subcenter. In fact, the female worker's responsibility
with regard to the subcenter goes beyond hygiene. She is expected to
stay there and run it on a day-to-day basis. This responsibility, how
■1
ever, which is not entrusted to the male worker, is not matched with
administrative authority over the subcenter. As a result, the male
worker does not report his activities to the female worker or even
necessarily feel accountable to the subcenter.
We recognize that the axes around which ANMs' experiences
revolve are the quality of their relationship with the community, their
positioning in the occupational hierarchy of the health services, the
nature and location of their health work (whether in a PHC or
subcenter, a developed or underdeveloped district, an accessible or
remote area), and their support mechanisms (professional, infra
structural, and personal). An examination of how these diverse ele
I
ments interact with one another and how they influence the quality
of care rendered by ANMs forms the core of this chapter.
i
w
I
J
J
i
Methodology and Sample
Our study is designed to generate an understanding of the socioeco
nomic background of ANMs, their role expectations, performance,
satisfaction, and problems from the health system and the commu
nity. It focuses on ANMs not as an operational category, but as women
in the hierarchical structure of the health services, and attempts to
document the many ways in which the health system affects their
lives and experiences.
The study is set in the four districts of Maharashtra that repre
sent its major geographic divisions: Ratnagiri District in Konkan, Pune
District in western Maharashtra, Beed District in Marathwada, and
Wardha District in Vidarbha. These districts are also representative
of particular levels of socioeconomic development as measured by
214
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra*'-**
the Centre for Monitoring the Indian Economy's (CMIE's) index of
socioeconomic development.1 In the mid-1980s, Pune District, with
an above-average index of 175, was considered to be an industrially
advanced district; Wardha and Beed Districts, with average figures
of 85 and 50, respectively, were moderately developed; and Ratnagiri
District, with a below-average index of 35, was classified as a back
ward district (CMIE 1987).
With the purposive selection of three talukas (subdistricts) in each
of these districts and two talukas in the tribal belt of Pune, and with
the random selection of two PHCs per taluka from a list provided by
the Directorate of Health Services, we identified 27 PHCs for partici
pation in the study. Using an open-ended interview schedule, we in
terviewed all ANMs working at the PHC and ea^h of the subcenters.
The interview schedule was designed to generate qualitative data and
to provide respondents with the opportunity to express themselves
freely. In addition, we selected five ANMs in each district for in-depth
interaction over a maximum period of three days. This enabled the
female researcher, who accompanied ANMs on their rounds, to en
gage in lengthy discussions and witness health activities undertaken
at the village level. She was aided by an interview guidebook designed
to help generate the same range of information as the interview sched
ule but in greater depth. Data collection commenced in the winter of
1990 and lasted until midsummer of the following year.
The total sample listing consisted of 210 ANMs; however, only
183 ANMs could be interviewed. The remaining 27 were on leave
(maternity or extended leave), in training, simply unavailable, or their
posts were vacant. Among the 183 respondents, 68 were from Pune
(42 from six PHCs in nontribal areas and 26 from three PHCs in tribal
areas), 50 from six PHCs in Wardha, 36 from six PHCs in Beed, and
29 from six PHCs in Ratnagiri. Of these 183 ANMs, 41 were posted at
their PHCs, 140 were in subcenters, and two were enrolled in train
ing courses at the district headquarters.
I
TABLE 11.1
Profile of ANMs: Rural Maharashtra, 1990-91
■I
Mean age at beginning of training (years)
20.5
Mean age at first posting (years)
Marital status at first posting (%)
Unmarried
Married
Separated, deserted, or divorced, widowed
22.7
Socioeconomic indicators
Location of current posting (%)
In native district
Outside native district
Rural versus urban background (%)
Rural
Semiurban or urban
1" I'
; iII
111
-■■m I
&
IL
&
.
Community of origin (%)
High caste
Middle caste
Scheduled caste or tribe
Christian or Muslim
Education (%)
Some secondary or high school
Matriculation
Intermediate license, junior college, or graduation
(No. of ANMs)
69
25
6
72
28
66
34
34
38
19
9
10
67
24
(183)
■
Note: Percentages may not add to 100 because of rounding
ANM=auxiliary nurse-midwife.
subcentersz the quality of their facilities, deficiencies in the performance
of the ANMs, and problems caused by family planning targets.
Socioeconomic Background of the ANMs
Findings
Our analysis focuses first on the social and economic backgrounds of
the ANMs, their training as health providers, and their professional
and interpersonal support within the health care system. Subsequent
sections examine the political and social conditions at the PHCs and
215
Aditi Iyer • Amar Jesani
Ji
>
ANMs are accepted into training schools at a young age (an average
of only 20.5 years in our study) (Table 11.1). By the time they gradu
ate from the training schools and receive their first posting in PHCs
and subcenters, they are two years older (the mean age in our study
was 22.7 years). More than two-thirds of all ANMs in our sample were
single when they began working in the rural health system. Instead
of using place of birth as the sole criterion for determining their back
grounds, we sought information on the places where they had stud
ied to understand their exposure to rural or urban life. Accordingly,
we classified ANMs who were born in rural areas and had their pri
mary and secondary education in rural areas as having rural back
grounds. The rest, by default, were considered to have urban back-
21b
-
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra
1
grounds. Two-thirds of the ANMs had rural backgrounds, and a third
were from semiurban or urban areas. The one-third of ANMs with
urban backgrounds—mainly Christians and Muslims—had had little
exposure to rural life before their recruitment. Therefore, the ANMs
brought with them youth and inexperience, which made working in
conservative and patriarchal social settings an especially daunting
I
TABLE 11.2
ANMs’ current economic role: Rural Maharashtra, 1990-91
Unmarried
ANMs
Ever-married
ANMs
All
ANMs
-1
Role
%
(No.)
%
(No.)
%
(No.)
•1 i
Sole earner
8
"W
22
(32)
19'
(35)
One of two earners
Earning more than husband or father
Earning as much as husband or father
Earning less than husband or father
37
3
(14)
(6)
(46)
(10)
(37)
33
6
24
(60)
16
No knowledge or cash income not earned
37
(14)
32
7
26
14
(20)
19
(34)
(No. of ANMs)
100
(38)
100
(145)
100
(183)
■ s
&
To be effective, ANMs must establish a strong, credible presence
in the community. Because they are seldom posted in their native vil
lages (although nearly three-fourths of those in our sample were
posted within their native districts), they are expected to build rap
port with strangers. Nor is this a one-time expectation. Transfers,
which occur every four years on average, ensure that ANMs spend a
large part of their career attempting to establish amicable relations
with largely unfamiliar communities.
Nearly three-fourths of the ANMs in our sample belonged to
upper and middle castes, nearly one-fifth belonged to lower castes
(scheduled castes and tribes), and fewer than one-tenth were Chris
tian or Muslim. Middle-caste Hindus dominated our sample, account
ing for 38 percent. Scheduled castes were overrepresented (nearly 18
percent as compared with 11 percent in the state, according to the
1991 census), and scheduled tribes were underrepresented (at nearly
2 percent as against 9 percent in the state). Similarly, within the group
of minorities, Muslims were underrepresented (nearly 2 percent as
against the 1981 census figure of 9 percent) and Christians overrepre
sented (nearly 8 percent as against the 1981 census figure of 1 percent)
The representation of lower castes (chiefly scheduled castes) and up
per castes, as evidenced by the caste variation among ANMs of differ
ent ages, has mcreased since 1980; the percentages of minorities (Chris
tians and Muslims) and middle castes has correspondingly declined.
Two-thirds of the ANMs in our sample had completed their sec
ondary education, a fourth had earned an intermediate certificate or
attended a junior college, and the remainder had received
OCvsome secondary education. Nearly a third of the sample had acquired additional
training, mostly in clerical skills such as typing and stenography.
Although a majority of the ANMs came from middle- and upfT.03316 families'many came from somewhat precarious socioeconomic situations.
At the.ime
ti: of recruitment, 64 percent of the ANMs
----------
Aditi Iyer • Amar Jesani
-
I
I
■
f
I
I feI
I
h ■
Ii|
■i r
■
■■
? r
I
(D
(11)
(43)
Notes: Percentages do not add to 100 because of rounding Brother's income considered if father had died
ANM=auxiliary nurse-midwife.
from rural areas belonged to landless and poor peasant families. Fur
ther, the monthly cash income of the ANMs' fathers averaged Rs738,
the amount varying only slightly across the four study sites. Worsen
ing the precarious financial position of the family were economic de
pendencies in the household at the time of the ANMs' recruitment:
on average, three to four dependents per earner or productive family
member. This was due in part to the fact that at the time of recruit
ment, one in four of the ANMs came from households in which the
father either had died or was economically inactive.
Consequently, the ANMs' wages contributed important eco
nomic stability to their households. One-fifth were the sole earners
in their families, and one-third of all ANMs commanded higher wages
than their husbands, fathers, or brothers (in the absence of a father)
(Table 11.2). The ability to alleviate the economic hardship of their
households motivated many of these women to join the government
service. Over time, the ANMs encountered numerous obstacles in
their work but could not dare to contemplate a job switch. Their de
pendence on their current employers was heightened by a realiza
tion that avenues of alternative employment were limited.
ANMs did not find many options in the labor market prior to
their employment in the Family Welfare Programme. Indeed, the role
of choice in their decision to work as ANMs was small. The most fa
vored occupation—one with fixed hours of duty, an attractive sal
ary, job permanence, and a reassuringly large female representation—
was teaching, which nearly three out of four perceived as a concrete
I
I
I
218
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra
option after their matriculation but were unable to achieve. More
over, four-fifths would have liked to pursue higher studies but were
prevented from doing so by the fragile economies of their households
All these factors contributed to the vulnerability of ANMs and, con
sequently, their bargaining power vis-a-vis the health bureaucracy
and the community.
Training
In the 1950s and 1960s, training courses for ANMs focused on mid
wifery and MCH, with 9 out of 24 months earmarked for those sub
jects. In 1973 the government integrated the various functions of the
health services, changing the ANMs' role (Kartar Singh Committee
1973). Two years later, a government committee called for an expan
sion of their training to prepare them for multipurpose health work
(Snvastava Committee 1975). In response, the Indian Nursing Coun
cil approved an expanded syllabus in 1977 (Indian Nursing Council
1977). However, the expansion in training requirements was not
matched by a longer period of training. On the contrary, with the new
syllabus came the decision to reduce the training period from 24 to
18 months, which some nurse trainers consider inadequate to pre
pare ANMs for work at the village level (Deodhar 1994). Compro
mises in the length and quality of training affect recruits' confidence
and efficiency (Prakasamma 1989).
In Maharashtra the training standards received another setback
in the 1980s, when vacancies in the public health system in rural ar
eas generated an urgent demand for ANMs there. A frenzied attempt
to recruit women for the job ensued. By the end of the decade, with
7,471 additional ANMs pressed into service, the cadre had swollen
to twice its earlier size. This came about not by a redistribution of the
3,797 fully trained ANMs from the nongovernmental sector (who rep
resented nearly one-half of all registered ANMs), but rather by ex
panded enrollments in training schools and by the induction of un
registered personnel. The unregistered ANMs accounted for 71
percent of all recruits during the 1980s (Iyer and Jesani 1995). This
trend is reflected in our data. Three out of four ANMs currently em
ployed were recruited during the period 1981-91. Among that group,
42 percent were still unregistered with the Nursing Council at the
time of our interviews.
Aditi Iyer • Amar Jesani
1 IS’■
E
L
I
1
Er
ai
I|
r
1r
■
JI
I
219
The chief architect of this trend was the state government. In 1982
it introduced a so-called Step Ladder Course, which further reduced
the training period from 18 to 12 months and located nearly all its
’ re
instruction in the field instead of the training school. Given the
duced standards of this course, it failed to win the immediate approval
of the Maharashtra Nursing Council. Eventually the Nursing Coun
cil and the state government worked out a compromise: the Council
agreed to register probationary workers provided they were put
through another six months of training and examinations at the end
of it, and the state instituted Step Ladder Promotional Courses at sev
eral training centers and began sending its workers to them.
This reduction in minimal training standards and its subsequent
legitimization has had several far-reaching implications. First, by not
providing enough time for students to assimilate the course mate
rial, it inadequately prepares young and inexperienced women for
their jobs. Most ANMs trained under the Step Ladder Course com
plained to us that too much information had been imparted in too
short a time. Second, ANMs' registration is now controlled by two agen
cies, the state bureaucracy and the Nursing Council. For ANMs, who
are considered to be temporary workers until they are registered, the
politics surrounding their formal acceptance by the health system only
intensifies the insecurity that their deficient training has engendered.
Their temporary status prevents them from receiving wages commen
surate with their full-time work, and their eligibility for basic employee
benefits is subject to the whims of the district-level administration.
Although the 18-month MPW course is superior to the Step Lad
der Course, it places an unwarranted emphasis on hospital-based and
nonnursing activities, even though ANMs' role requires an orienta
tion to outreach work. A radical reorientation of the content and peda
gogy of training is needed not only in the Step Ladder Course but
also in the 18-month MPW course.
In sum, young and vulnerable women who aspire to become
ANMs receive an unrealistic preview of their future career in the train
ing schools. In shielding them from responsibilities, nursing schools
fail to build trainees' confidence, a vital asset in unassisted health
work, which requires independent decisionmaking. Moreover, their
cloistered existence in the school does little to prepare them for work
in unfamiliar, often uninviting, village communities. The threat of
sexual harassment and abuse mars the careers of most ANMs, but
22u
Aditi Iyer • Amar Jesani
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra
trainees are not informed of their legal rights or channels of redress.
in the end, ANMs learn their lessons of village-level health work not
in training schools, but while negotiating the numerous hurdles they
encounter in everyday life.
1
4
■.
Professional and Supervisory Support
:■
Once ANMs are out of training schools, they need professional sup
port to help them carry out the tasks assigned to them. This need is
particularly acute in subcenters, where ANMs are deprived of the re
assuring environment of a health campus. ANMs need to go through
periodic retraining programs and ongoing, continuous supervision.
In the PHC setup, the medical officer and health assistants (male
and female) are responsible for supervising ANMs as well as male
MPWs, dais (traditional birth attendants), and community health vol
unteers (CHVs). Lady health visitors (LHVs), the female supervisors
of ANMs, are no more than experienced paramedical staff who are
given additional training for six months. Besides supervising ANMs,
their duties include providing guidance to ANMs, strengthening their
knowledge and skills, helping them to plan and organize their activi
ties, making weekly visits to subcenters, and making home visits to
observe and guide them in their day-to-day activities. Medical offic
ers are also expected to make weekly visits to the subcenters and at
tend clinics organized there to examine and treat difficult cases. They
are also expected to hold monthly staff meetings at the PHC to evalu
ate workers' progress and suggest improvements. During those meet
ings, they convey information from their meetings with the district
health officer, inform staff about campaigns and surveys proposed
by the district-level administration, monitor existing activities, and
outline work schedules for the next month. Sometimes they accom
pany this with a short lecture on a health activity of their PHC.
Supervision should consist not merely of technical guidance but
also of moral support and encouragement. In reality, this does not
happen. In one of the PHCs, for example, ANMs belonging to the
same caste as the medical officer were given preferential treatment;
m another, the medical officer's wife, who was an ANM, did no work'
but was not reprimanded. An ANM in Wardha was convinced that
her medical officer was penalizing her for her assertiveness by refus
ing to cooperate with her. Once, she told us, he kept putting off per-
I
I'-'
1 Il ’
If-
I
t
■
forming a tubectomy for a woman she had recruited. Another time,
when there were no empty beds in the ward, he ordered her to bring
a cot from home for one of her sterilization cases and after the opera
tion refused to let her take it back home in the PHC's jeep. His be
havior made her job especially difficult.
The hierarchical relationship between medical officers and ANMs
erects barriers between the two functionaries that reduce whatever
bargaining power ANMs might otherwise muster. An authoritarian
medical officer in Wardha required his staff to stand at attention while
addressing him. He discouraged staff unity by inviting tattling, which
created an atmosphere of mistrust. ANMs were sometimes expected
to help the medical officer in his private practice or to manage the
clinic for outpatients with the compounder (medicine dispenser) in
the medical officer's absence. An ANM who was separated from her
husband reported the medical officer made sexual advances toward
her, suggesting that they "have fun" at a lodge in the town. When
she refused, he retaliated by issuing a memorandum critical of her
performance. Countering these reports of harassment, however, were
reports by other ANMs who gratefully acknowledged interventions
by their medical officers that helped resolve difficult confrontations
with community leaders. One of the medical officers even reduced
an ANM's work load when she was undergoing a personal crisis.
Another criticism voiced by our informants was that their su
pervision consisted of little more than monitoring contraceptive-ac
ceptor targets and making perfunctory inspections. Their supervisors
treated the achievement of targets as the only indicators of perform
ance, zealously emphasizing them in individual interactions and in
monthly meetings at the PHC. This finding is echoed in other studies
(Durgaprasad et al. 1989; IIHMR1991; Nichter 1986). Indeed, monthly
meetings often became trials at which ANMs were publicly repri
manded for not completing targets assigned to them. This pressure
intensified toward the end of the fiscal year (in March). As a result,
the ANMs were sometimes driven to falsifying their records to exag
gerate their accomplishments. They expected to gain little useful in
formation from the monthly meetings; in fact, few looked forward to
them, and many set aside their routine health activities for one or
two days before those encounters to complete their records.
The content of supervision ranged from active encouragement
to indifference, non-cooperation, and even antagonism, depending
4
J
222
on the medical officer's attitude to nurses in general and individual
ANMs in particular. Most medical officers issued reprimands more
often than praise. Some ANMs received no supervision at all. Those
in the more remote subcenters complained that the LHVs rarely vis
ited them because they were put off by the prospect of walking long
distances on their own. We came across some instances in which
ANMs worked in close association with their health assistants, but
these were the exception. In general, the intent, consistency, and qual
ity of supervision left much to be desired.
11
II
TABLE 11.3
Time utilization of ANMs on the last working day prior to interview:
Rural Maharashtra, 1990-91
_____________
I
B’
Location and activity
11 K
PHCs
Home visits
T ravel
Outpatient departments or clinics
Record writing
Universal Immunization
Programme camps
Deliveries
Meetings
Transporting family planning cases
Other activities
Not applicable or on leave
(No. of ANMs) and average workday
3 K
..••I* p
Social Conditions and Vulnerability ofANMs
ANMs are posted either at a PHC or at any of the subcenters under
its jurisdiction. Some 77 percent of the ANMs in our study were posted
at subcenters, while 23 percent were working in PHCs, a distribution
not markedly different from the average for the state of Maharashtra
as a whole. PHCs tend to be located in more developed villages,
whereas subcenters are located in remote villages or in outlying ar
eas of larger villages. At the PHCs, ANMs work within the structure
of a health campus or at least have a visible backdrop for their work
in the community. This includes the presence of the health team,
headed by a doctor, and health infrastructure with facilities for a daily
outpatient department. In contrast, ANMs posted to subcenters work
unassisted, receiving only transient professional guidance from the
medical officer or female health assistant. The presence of a medical
officer at a weekly clinic organized by the ANM at the subcenter,
though mandatory, is a rarity. Therefore, rather than operate clinics
at the subcenter building, ANMs tend to deliver health care to their
communities through house-to-house visits. While taking stock of the
activities conducted by ANMs on the day of our interview and the
time spent on each activity, we found that slightly more than onehalf (55 percent) of the ANMs posted at subcenters made home vis
its, compared with only one-quarter of those posted at PHCs (Table
11.3). Both groups of workers spent an average of four hours, or threefifths of their working day, on house-to-house visits.
The mandated population size of an ANM's territory is 5,000
(3,000 in tribal and hilly areas). Among the ANMs in our study it was
4,565, somewhat less than the average of 5,168 for the state in 1991.
However, most ANMs were without transport and had to walk long
223
Aditi Iyer • Amar Jesani
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra
11Bll F
I
'•Oi-
I ■W: li
Subcenters
Home visits
Travel
Outpatient departments or clinics
Record writing
Universal Immunization
Programme camps
Deliveries
Meetings
Transporting family planning cases
Other activities
Not applicable or on leave
No response
(No. of ANMs) and average workday
is fcfil
S
SS*£'z-;5iife> -z
.- B
11 •
- Sk
<1.1
3 83
■
I ||-3
K
. = pfe- .
jfe-'W ■
li
All locations
Home visits
Travel
Outpatient departments or clinics
Record writing
Universal Immunization
Programme camps
Deliveries
Meetings
Transporting family planning cases
Other activities
Not applicable or on leave
No response
(No. of ANMs) and average workday
ANMs
% (No.)
Average
Percentage
duration
of average
of activity
workday
(hours:minutes)
24
10
73
22
(10)
(4)
(30)
(9)
3:47
1:49
4:56
1:40
52
25
68
23
12
20
7
(5)
(8)
(3)
(0)
(6)
3:18
3:11
4:50
46
44
67
4:00
55
15
2
(D
(41)
7:13
55
41
15
30
(77)
(57)
(21)
(42)
4:10
2:03
4:05
2:21
62
31
61
35
16
6
9
3
17
5
1
(22)
(8)
(13)
(4)
(24)
3:58
4:09
5:01
2:45
2:34
60
62
75
41
38
(7)
(1)
(140)
6:40
48
34
28
28
(87)
(61)
(51)
(51)
4:08
2:02
4:35
2:17
60
30
67
33
15
9
9
2
17
4
1
(27)
(16)
(16)
3:51
3:40
4:59
2:45
2:51
56
54
73
40
42
(4)
(30)
(8)
(1)
(181)
6:50
Notes: Numbers of ANMs exclude those in training. The average duration of individual activities in
each of the subgroups does not add up to the average work day because of multiple responses.
ANM=auxiliary nurse-midwife; PHC=primary health center.
• peuence oi Auxiliary Murse-Midwives in Rural Maharashtra
Aditi Iyer • Amar Jesani
TABLE 11.4
Provision of government accommodation: Rural Maharshtra, 1990-91
Type of accommodation
Government quarters
PHC
ANMs
Subcenter
ANMs
All
ANMs
58
42
17
83
26
74
No government quarters
Total
100
(No. of ANMs)
(41)___________(140)
100
i
K
mil
100
(181)
ANM=auxiliary nurse-midwife; PHC=primary health center.
B
Ii
distances under the blazing sun, sometimes through desolate and dan
gerous terrain. One-third of all ANMs spent an average of two hours,
or a third of their workday, commuting between their workplace and
the villages under their charge. Among those assigned to subcenters,
41 percent spent that much time commuting, as compared with 10
percent among those posted at PHCs. This travel time was in addi
tion to the time it took ANMs who lived outside the village where
they were posted to reach the subcenter.
ANMs have numerous reasons for preferring not to live in their
subcenters. Personal safety is a major concern, especially for unmar
ried and separated women, who are most vulnerable to sexual ha
rassment. All ANMs, particularly those living in subcenter villages,
require secure living quarters. However, a distinct bias favors ANMs
posted at PHCs: 58 percent of ANMs posted at PHCs, as compared
with only 17 percent of those posted at subcenters, were provided
with government quarters, whether they occupied them or not (Table
11.4). Despite the shortage of living quarters, 59 percent of all
subcenter ANMs were residing in the villages to which they were
posted (data not shown), and three out of four of them were doing so
without being provided with quarters.
C
In the course of their health work, ANMs are exposed
exposed to
to com
com-
munity politics and prejudices. As we have mentioned, the disadvan
tages already imposed on women by a patriarchal and caste-based
social system are compounded in their case by the association, in many
Indians' minds, of the nursing profession with pollution and disre
pute. Because ANMs' work requires them to speak openly about con
traceptives, to interact with men as well as with women, and to keep
itinerant schedules, they are viewed as women of loose morals. This
negative social image and their low status within the health system
>I
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11
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■
■
make them easy prey to sexual harassment a prospect that plagues
them throughout their careers.
Unmarried or maritally disrupted women, who are believed to
be unspoken for or who do not visibly display the protection of their
families, are particularly vulnerable to sexual harassment. A number
of the ANMs in our sample recalled how their social position in the
community changed after their marriage. The lewd propositions and
taunts that came their way before marriage stopped as soon as they
had the protection of their husbands. This was particularly the case
in Wardha District, where social relationships tended to be more feu
dal. One of the ANMs in Pune District, a young divorcee, also re
called an unpleasant incident involving a man who approached her
late one evening for a medical certificate. It soon became apparent
that he had an ulterior motive; had she not slammed the door shut
against him, she believed he would have molested her.
Another kind of harassment emanates from village leaders, who
demand special services, such as immunizations, at their homes. In
one village, a sarpanch (elected village head person) kept a close eye
on the ANM; another insisted that he be allowed to inspect her
records; yet a third badgered the ANM because she did not dispense
vitamin tablets (a difficult task since she had no supplies); and a fourth
made unjustified complaints to the district health officer before or
dering the ANM to leave the village and never return.
A third pretext for mistreating ANMs is their caste affiliation. In
Wardha several ANMs from lower castes mentioned that they laced
overt discrimination. One of them, a 36-year-old neo-Buddhist, leported that higher-caste groups who were dominant in the area gave
her tea in broken cups, made her sit on a sack on the floor, did not
allow her to touch them, and before her own eyes would throw away
the medicines she gave them. Conversely, a few of the ANMs from
higher castes in Ratnagiri were visibly uncomfortable dealing when
people of lower castes.
When an ANM arrives in a new village, she usually undergoes
a period of testing by certain groups in the community (often youths),
who accost, tease, or even sexually harass her. One of the older ANMs
in Ratnagiri recalled the problems she had in her first posting. Her
clients would become agitated over the onset of fever after an immu
nization. When she approached them with family planning informa
tion and contraceptives, they would say: "Why are you bringing us
226
what you have left over?" or "Why don't you use them yourself?"
An ANM in Wardha described the early days of her stay in the
subcenter village to which she was currently posted. People would
stone her house in a bid to drive her out, so that the previous ANM
would return. Young boys would drive to the steps of the subcenter
on their bicycles and frighten her and her young daughter. The ha
rassment lasted for a year and a half.
The Quality ofPHC and Sub center Facilities
Ideally, PHCs should be staffed with two ANMs, one handling work
within the PHC itself, and the other conducting outreach activities in
the community. Disguised understaffing exists, however, the magni
tude of which can be gauged from state-level statistics compiled by
the Directorate General of Health Services. In 1991, Maharashtra's
1,650 PHCs, which should have had 3,300 ANMs, had a shortfall of
1,376, a figure more than 14 times higher than the number of vacan
cies reported in official statistics that year. Under such circumstances,
ANMs, many of whom are forced to handle the jobs of two individu
als, naturally feel overburdened.
Despite an increase in the number of PHCs during the 1980s,
the provision of buildings to house the new centers came only later.
In 1987 fewer than one-half of the PHCs had regular buildings, but
by late 1993 nearly all of them did (GOI, CBHI 1988-94; GOI, DGHS
1988-94; GOI, MOHFW 1988-94). In contrast, only about one-half of
the state's subcenters had regular buildings by late 1993. The PHCs
and subcenters remain inadequately equipped and supplied. These
problems affect the system's capacity to provide health care services
of satisfactory quality, and ANMs bear the brunt of those problems.
To perform their work, the ANMs assigned to subcenters require
not only secure living quarters but also a well-constructed building
and essential equipment and supplies. Their physical working con
ditions fall far short of that ideal. Fewer than one-fourth (24 percent)
of the ANMs posted at subcenters in our study had a specially con
structed building. Thirty percent either had no subcenter space at all
or had to conduct health activities from their homes, and the remain
der worked in a rented room or in space provided by the panchayat
(village council) or local government (Table 11.5). Of the 118 struc
tures used for subcenter activities, one-third were poorly constructed.
227
Aditi Iyer • Amar Jesani
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra
fc-
TABLE 11.5
Subcenter facilities, essential furniture, and basic equipment:
Rural Maharashtra, 1990-91
I t ;:
I
EWKW*' ■
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IE
Facilities and equipment
Facilities
Rented room/other government premises
Specially constructed building
No subcenter space
No separate building; run from ANM's house
Basic equipment or furniture
Stove
Fetoscope
Weighing machine
Chair/stools
Table
Autoclave
Cupboard
Delivery/examination table
Bench
Stethoscope
Blood-pressure instrument
(No. of ANMs posted at subcenter villages)______________ (14°)
Percentage
of ANMs reporting
46
24
16
14
79
64
64
45
39
35
32
31
29
21
16
Note: Percentages do not add to 100 because of multiple responses.
ANM=auxiliary nurse-midwife.
More than a quarter of them lacked electricity, and as many as 71)
percent did not have a piped water supply (data not shown).
Although subcenters constructed by the government were bet
ter than makeshift rental arrangements, they were usually located at
the village periphery or outside the protection of the main village clus
ter. ANMs were afraid to live in those structures unless they had their
families with them. Rented rooms that served as subcenters were lo
cated within the villages but were often dark and dingy, and most
offered no privacy to the ANM or her patients.
The subcenters were not adequately or uniformly equipped. For
example, a common item is the stove, because it has many general as
well as health uses. Yet, out of the 140 ANMs posted at the subcenters,
one in five lacked this basic amenity. Apart from the stove, the only
other instruments we found in most of the subcenters were a
fetoscope, either as part or independent of a delivery kit (64 percent),
and a weighing machine (64 percent). Certain essential instruments
'* ? care were found in fewer than half of
for preventive and curative
subcenters. These included the autoclave (35 percent), stethoscope (21
percent), and instrument for measuring blood pressure (16 percent).
228
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra
Essential items of furniture such as chairs or stools (45 percent), cup
boards (32 percent), a delivery/examination table (31 percent), and a
bench (29 percent) were also found in a minority of instances.
These inadequacies affected the ability of ANMs to work with
any degree of confidence in the community. Three-fourths of all
ANMs in our study had multiple complaints about their working
conditions. Besides being overburdened, they cited the inadequacy of
facilities, equipment, and medicine stocks. They also complained about
the lack of proper accommodation and inadequate transport facilities.
ANMs are expected to conduct at least half of the deliveries in
their areas; but, by our estimates, ANMs based at PHCs and subcenters
conducted no more than 19 and 13 percent of deliveries, respectively.
They attributed their inability not only to their sense of inadequacy,
due in part to their deficient training in this area, but also to the lim
ited facilities available to them and their having to function in isola
tion. That is why two-thirds of the deliveries they attended took place
in the women's homes, in most cases under far from ideal conditions.
Having to leave their subcenters for this work exposed them to
sexual harassment. Stories of the experiences of ANMs who had been
drawn out of their homes at night under false pretenses, only to be
molested or raped, spread among ANMs and were lodged in their
collective experience. As a result, the ANMs tended either to shun
health work after 8:00 p.m. or to live outside their assigned villages
so that they would not be expected to make night visits. Many ANMs
refused to budge after dark unless their attendants or CHVs could
accompany them.
Divergent Health Priorities
The ANMs in our study, including those posted at PHCs, conducted
an estimated 15 percent of all deliveries in their areas, fulfilled 64 per
cent of their targets for sterilization and 65 percent of their targets for
intrauterine device insertions, and reported that they were providing
curative services to 68 percent of all those who approached them. If
ANMs could do all the work expected of them, they would indeed be
regarded as important workers at the village level. The reasons why they
cannot do this lie in their assigned priorities, their resulting allocation of
time, and the highly deficient support mechanisms available to them.
■te?
f
Aditi Iyer • Amar Jesani
*
I
I
The Family Welfare Programme has steadily overshadowed all
other programs and services of the primary health care system.
SB
||s .
Changes in health policy affect ANMs directly. They are expected to
implement health policies through their activities at the village level.
By virtue of their position in the community, however, ANMs are
faced also with demands for other health services by the people they
are supposed to help. The government and villagers do not always
share the same priorities, and, in trying to accommodate both, ANMs
w
t
often end up caught in the middle.
We asked the ANMs we surveyed to rank eight health activities
from the perspective of the government and the people. Their combined ranking reveals a conflict between the community members,
whose highest priority is curative services, and the government,
■1
t
I
whose perceived priority remains family planning.
Government priorities directly affect budgetary and financial al
allocations, which in turn affect the provision of equipment and sup
plies. As a result, PHCs may experience gross deficiencies in essential drugs but are invariably well-stocked with contraceptives (ICMK
(w ivik
1991). This deficiency not only limits the ANMs' ability to provide
tangible services at the point of contact with the community but also
reduces their credibility. "You don't give us medicines when we need
them; why should we listen to you when you tell us about family
plannmg?' was a refrain that the ANMs in our study were obliged to
hear over
over and over again. To rectify the communities perception of
hear
their
their role
role as
c superfluous and self-serving, they placed great emphasis
' on their curative work and less emphasis on their function as midwives.
ANMs attempted to honor as many requests for medicines as
possible in an effort to gain acceptance in the community, a practice
that has also been documented elsewhere (Paul, Singh, and Sharma
1988). Every year subcenters in Maharashtra receive an annual pro
vision of drugs and supplies valued at only Rs3,000. Despite that in
■
adequate level of support, ANMs posted at subcenters and PHCs in
our study reported that they were able to provide curative care to an
-------- j of two-thirds of all clients who approached them.
average
Pressed for medications, the ANMs referred patients to the PHC,
3B-;
rationed their stocks by giving patients medicines in smaller doses
than indicated, or simply turned them down. A few were driven to
dispensing innocuous drugs or placebos to satisfy clients. Others pur-
IIfew'
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230
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra
chased and dispensed medicines in a private capacity. Inadequacies
in drug provision—and ANMs' deficient training in drug use—thus
threaten the rationality and quality of health care available from PHCs
and especially from subcenters. This conclusion is reinforced by find
ings reported by Phadke and colleagues (1995) in Maharashtra and
by Paul, Singh, and Sharma (1988) in Uttar Pradesh.
ANMs told us they hoped that their curative activities would
have a positive effect on their family planning performance. To in
crease their credibility, most (64 percent) conducted antenatal care,
deliveries, postnatal care, and immunizations (Table 11.6). And
through all of this, ANMs continued to promote the economic ben
efits of small families (mentioned by 52 percent of the ANMs) or the
health benefits to the women and their children of limiting their fam
ily size (mentioned by 39 percent). Accompanying these strategies
were a host of monetary and material incentives they offered clients,
including the provision of meals and snacks to the women and the
relatives who accompanied them to the PHC, medicines and injec
tions during and after sterilization, and a personal monetary, contri
bution to augment the government's monetary incentive of Rsl30 for
each sterilization.
Interestingly, ANMs were reluctant to admit that they relied on
incentives; a mere 16 percent did so at first. It was only when we asked
them to outline the motivational strategy they had employed in their
last case that they admitted having offered incentives. Nearly twothirds had given their last client food, 57 percent had bought her medi
cine or an injection, 37 percent had topped up the regular motivation
fee offered by the government with their own contribution of approxi
mately Rs200, and nearly a third had reimbursed the woman for her
travel expenses.
Mr
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The Burden of Family Planning Targets
Since their institution, family planning targets have become yardsticks
by which ANMs are judged and accordingly rewarded or punished.
The rewards consist of praise at monthly meetings of PHC staff, a
cash prize, or a certificate from the district health officer. Punishment
includes the withholding of an ANM's salary (sometimes for three
months at a stretch), a reprimand in the presence of other staff at a
monthly PHC meeting, a memorandum criticizing the worker's per-
■■
231
Aditi Iyer • Amar Jesani
TABLE 11.6
Strategies and material incentives employed by ANMs to motivate women
to use family planning methods: Rural Maharashtra, 1990-91
Strategies and incentives
Motivational strategy (% of ANMs using)
Building credibility through other health services
Promoting the ideal of a small family for
nation’s development
Advising women to have fewer children
to protect their health
Building rapport, explaining things in identifiable terms
Providing monetary and other material incentives
Promoting the ideal of gender equality
Excluding men, targeting only women for motivation
Other methods
Motivation not required
Not stated
Incentives given for sterilization (% of ANMs offering)
Meals or snacks for patient and relatives during stay
Medicines or tonics before, during, or after acceptance
Augmentation of sterilization incentive fee
Reimbursement of travel expenses
Other
PHC
ANMs
Subcenter
ANMs
All
ANMs
63
64
64
46
54
52
37
42
7
5
5
2
5
7
39
34
19
9
5
1
0
0
39
35
16
8
5
1
1
2
62
57
29
33
66
57
39
30
7
65
57
37
30
7
(No. of ANMs offering incentives)
10
(21)
(74)
(95)
(Total no. of ANMs)
(41)
(140)
(181)
Note: Percentages do not add to 100 because of multiple responses.
ANM=auxiliary nurse-midwife; PHC=primary health center.
formance, and on rare occasions, termination of employment. ANMs
tend to receive more punishments than rewards.
Targets, we were informed, worked wonders for some workers
in more remote districts. Recruitment of one or two family planning
acceptors often resulted in a desired transfer or extraordinary favor
from the district administration. This saw several government ser
vants—teachers, gram sevaks (village clerks), and talatis (revenue settle
ment officers) joining the fray and competing with ANMs for clients.
Because they had no quotas to fulfill, however, they could afford to
be extravagant. Some offered women as much as Rs400 to agree to
have a tubectomy. This set up a market economy at the village level,
and women began demanding a proper price for their impending ster
ilization. ANMs were now expected to make more out-of-pocket pay
ments. They offered travel expenses for the women and their accom
panying relatives in addition to food during the women's stay at the
PHC. Some offered a six-month course of vitamin B complex injec
tions following the operation. The most extraordinary request came
from one woman's husband, who asked the ANM to take his wife's
place while she was away at the PHC.
Targets distort what might otherwise become mutually benefi
cial relationships between ANMs and women in the community. This
problem is particularly acute in areas ridden with competition for fam
ily planning acceptors. Many of the ANMs in our study inculcated a
narrow perspective on women's health, regarding women primarily
as reproducers and targets for acceptance. This view often contrib
uted to the alienation of ANMs from the community.
Male leaders and youths used the ANMs' anxiety about meet
ing targets as leverage to establish political control over them or as a
pretext for sexual exploitation. In one area, a gram sevak promised
to recruit acceptors for an ANM if she would accompany him to a
lodge in town. In another instance, the police patil (village official ap
pointed to oversee law and order) wanted her to provide his sexual
partner, an unmarried woman who had no children, with a CopperT. When the ANM refused, he complained about her to the district
health officer. An unmarried ANM recounted how the village
sarpanch had approached her for an injection that would cause his
pregnant sexual partner to abort the fetus. Since ANMs were not sup
posed to conduct abortions, she refused. He then complained to her
supervisor. Instead of supporting her, the supervisor explained her
behavior by saying that because she was unmarried, she did not know
about such an injection. The supervisor even offered to administer
the injection herself. The sarpanch decided that the village should
henceforth have a married ANM and demanded that the ANM who
had refused his request be transferred.
Despite many negative experiences, caused in part by their as
sociation with family planning targets, many ANMs were unwilling
to denounce the system of targets. One-third of them believed that
removing targets would harm other aspects of their work (Table 11.7).
An equal proportion, however, favored the removal of targets, and
one-fifth thought that the removal of targets would have no effect,
either negative or positive, on their work.
The reason mentioned by most of those who took a negative view
of removing targets was that workers would be tempted to neglect
other health-related duties, because many ANMs tend to carry out
non-family-planning tasks with the expectation that they will have a
positive impact on their family-planning performance (that is, target
233
Aditi Iyer • Amar Jesani
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra
“.1
I
g
E •I
p
1 It-h-
TABLE 11.7
ANMs’ views on the effect of removing family planning targets:
Rural Maharashtra, 1990-91
Effect of target removal
Percentage having
specified view
Positive effect
33
Negative effect
33
No effect
20
Positive and negative
7
Cannot say
2
Other response
Not applicable (targets not given)
2
1
3
No response
Total
100
(No. of ANMs)
(181)
Note: Percentages do not add to 100 because of rounding.
ANM=auxiliary nurse-midwife.
■
TABLE 11.8
ANMs’ views on the hypothesized effects on health work of the removal
of targets, Rural Maharashtra, 1990-91
Hypothesized effects
Ii
III *
5
Ii
m
Negative
Other health activities will suffer
ANMs will suffer from a lack of direction
Family planning work will suffer or population will increase
There will be no substantial difference
Positive
Quality of family planning work will improve
Harassment, tension, expenses will diminish
Other health activities will improve
Relationship with community will improve
Relationship with colleagues will improve
Not applicable or no response
(No. of ANMs)
Percentage of ANMs
having specified view
44
30
18
23
21
20
17
10
2
5
(181)
Note. Percentages do not add to 100 because of multiple responses.
ANM=auxiliary nurse-midwife.
■
' 3s
E-.’-
fulfillment); 44 percent of the ANMs gave this reason (Table 11.8). This
argument found ideological resonance among 30 percent who believed
that they would lose a sense of purpose and direction. About 18 per
cent thought that the removal of targets would lead to large increases
in the population. One-fifth of the ANMs, on the other hand, felt that
the quality of their family planning work would improve. Nearly as many
234
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra
believed that the removal of targets would reduce the harassment aimed
at them, alleviate their tension, or lower their expenses. Seventeen per
cent felt optimistic that their other work would improve. One in 10 men
tioned that their relationship with the community would improve.
Thus, although activities related to family planning were an oner
ous burden for many ANMs, not all of them were willing to criticize
the program. Nor were all of them willing to discard acceptor tar
gets, despite the problems they created in their working lives. Their
induction and subsequent socialization into the existing health serv
ice program had given them a narrow view of their role and respon
sibilities in the health of rural communities.
Conclusion
The achievement of a high standard of care presupposes a concern
for quality assurance. Integral to quality assurance is the setting of
optimal standards for service delivery and outcomes. These concerns
have never been adequately emphasized in India's public health sys
tem. Instead, the achievement of targets has, until recently, been an
obsession at all levels of the health bureaucracy. The removal of tar
gets may be seen as a first step in the establishment of a quality frame
work. However, this will have to be backed up by uniformly avail
able and accessible health institutions and practitioners. Some of these
preconditions have not been achieved in India.
First, the quantitative expansion of the health system has been a
bureaucratic exercise; it has been created on paper and only later pro
vided with personnel and infrastructure. By the time the expanded
infrastructure attains an optimal level of performance, it is thoroughly
discredited among the people whom it is meant to benefit. Health
workers then require years to change people's negative opinion about
the services provided.
Second, selective health care has been the single most important
cause of the low utilization and negative image of the health care serv
ices. In rural areas, where people have few alternatives, selective
health care has meant ignoring people's basic health needs. The In
dian program s overemphasis on family planning, coupled with the
neglect of basic curative care, has created the impression among the
populace that the government is interested in little more than meet-
Aditi Iyer • Amar Jesani
I
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1I Iff
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235
ing its family planning targets. Paradoxically, the extremely high pri
ority assigned to those targets has worked to the detriment of the pub
lic health system as a whole.
Third, it is difficult, if not impossible, to achieve a high quality
’ ‘ i care without having basic facilities for delivering it. Unfor
of health
f..
.—tunately,
the government's rural health care system is woefully deficient in basic physical standards of care, even though its; own depart
ments
tyiph
U and aapneies
agencies have laid out guidelines for them. 1This is one of
the reasons why the government has no moral authority to enforce
minimal standards of care in the unregulated and often irrational pri
vate sector. The deplorable conditions that exist in many PHCs and
subcenters require tremendous effort on the part of the health work
ers to provide even minimal care.
A fallout of poor public health services has been the increasing
dependence on home-based care. In contrast with the situation in de
veloped countries, home-based care in India does not complement highquality institutional services that can be relied upon in emergencies.
Rather, those who are driven to home-based care have hardly any sup
port systems—such as transport and communication—that they can
call upon in emergencies or when they need specialized referral care.
Fourth, ANMs are currently expected to function without close
and continuous supervision from medical and nursing profession
als. It is ironic that whereas institution-based paramedical workers
and auxiliaries in urban areas are precluded from an independent
role in health care delivery, rural auxiliaries, with virtually no medi
cal supervision, hospital facilities, or means for transporting patients
during emergencies, are expected to perform above their level of train
ing and without the assistance of medical professionals. The role of
auxiliary workers in health care and the quality of care expected from
them need to be carefully reconsidered and possibly redefined.
Finally, no health worker, let alone an ANM, can meet work ex
pectations in an atmosphere ridden with insecurity and anxiety. The
fact that the health care system is insensitive to concerns about their
security, and that some superiors contribute immeasurably to such in
security, undermines their ability to perform at optimal levels. An un
safe and inhospitable workplace does little to promote quality assurance.
The emerging concern among policymakers about the quality of
health care at PHCs and subcenters, though welcome, is belated.
236
Aditi Iyer • Amar Jesani
Experience of Auxiliary Nurse-Midwives in Rural Maharashtra
Health workers have complained in various ways about the prob
lems they face in the workplace. The present concern for quality must
now be translated into practical programs to alleviate their problems.
Otherwise, the objective of making quality an integral part of the pub
■I
lic system is likely to remain a distant goal rather than become a con
crete reality.
Acknowledgments
The study on which this chapter is based was conducted at the Foundation for
Research in Community Health, Mumbai, with financial assistance from the Dan
ish International Development Agency (DANIDA). We are grateful to Audrey
Fernandes, Seema Hirani, and Sandeep Khanvilkar, fellow researchers, not just
for participating in the study but for shaping its contours. We are also thankful
to our colleague Sunil Nandraj at the Centre for Enquiry into Health and Allied
Themes (CEHAT) and to Michael Koenig for their valuable comments on an
earlier draft of the chapter.
s
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■s BI
Note
1
The CMIE index, which is'a rough proxy indicator of the gross national
product, is a weighted average of indicators for three sectors of the
economy: the agricultural sector (per capita value of output of 26 major
crops and per capita bank credit for agriculture); the mining and manufac
turing sector (number of mining and factory workers per lakh [100,000]
population, number of household manufacturing workers per lakh popula
tion, and per capita bank credit for the manufacturing sector); and the serv
ice sector (per capita bank deposit, per capita bank credit to services, per
centage of the population literate, and percentage of the population urban).
l
■■2’
It
References
Centre for Monitoring Indian Economy (CMIE). 1987. District Level Data for Key
Economic Indicators with 70 Maps. Bombay (Mumbai): CMIE.
Deodhar, S. 1994. "Training of ANMs: An assessment," FRCH [The Foundation
for Research in Community Health] Newsletter: 8(5): 1-3.
Durgaprasad, P.z S. Srinivasan, N.G. Reddy, and P.K. Bhowmick. 1989. Health
Care Delivery System in Rural Areas: A Study of the Multipurpose Health Worker
Scheme. Hyderabad: National Institute of Rural Development.
Government of India (GOI), Central Bureau of Health Intelligence (CBHI). Vari
ous years. Health Information of India. New Delhi: Ministry of Health and
Family Welfare.
Government of India (GOI), Directorate General of Health Services (DGHS) Vari
ous years. Bulletin on Rural Health Statistics in India. New Delhi: Ministry of
Health and Family Welfare.
7
I
fi'- i
J
-
r
■
6- -•
Government of India (GOI), Ministry of Health and Family Welfare (MOHFW).
1996. Manual on Target Free Approach in Family Welfare Programme. New
Delhi: MOHFW.
--------- . Various years. Family Planning Year Book. New Delhi: MOHFW.
Government of India (GOI), Planning Commission. 1956. Second Five Year Plan,
1956-61. New Delhi: Planning Commission.
--------- . 1968. Fourth Five-Year Plan, 1969-74. New Delhi: Planning Commission.
--------- . 1992. Eighth Five-Year Plan, 1992-97, vol. 2. New Delhi: Planning Com
mission.
Indian Council of Medical Research (ICMR). 1991. Evaluation of Quality of Family
Welfare Services at Primary Health Centre Level: An ICMR
1CMR Task Force Study.
New Delhi: ICMR.
Indian Institute of Health Management Research (IIHMR). 1991. Training Needs
of Health System Functionaries in the State of Maharashtra. Jaipur: IIHMR.
Indian Nursing Council. 1977. Syllabi and Regulations for the Courses of Studies for
Auxiliary Nurse Midwife. New Delhi: Indian Nursing Council.
Iyer, A. and A. Jesani. 1995. Women in Health Care: Auxiliary Nurse Midwives.
Bombay (Mumbai): Foundation for Research in Community Health.
f
Jesani, Amar. 1990. "Limits of empowerment: Women in rural health care," Eco
nomic and Political Weekly 25(20): 1098-1103.
Kartar Singh Committee. 1973. Report of the Committee’ on Multipurpose Worker
of India.
Linder Health and Family Planning. New Delhi: Government
Gov<
Mukherjee Committee. 1966. Report of the Committee Appointed
to
Review Staffing
Ap}
Planning Programme. New Delhi:
Pattern and Financial Provision under Family Planning
Government of India.
Nichter, M.A. 1986. "The primary health centrej as a social system: PHC, social
status and the issue of team-work in South Asia," Social Science and Medi
cine 23(4): 347-355.
Paul, D., J.V. Singh, and A.K. Sharma. 1988. "Qualitative and quantitative as
sessment of medication of sick persons provided by ANMs in a primary
health centre," in National Seminar on Essential Drugs in Primary Health Care
in India: A Report. New Delhi: National Institute of Public Cooperation and
Child Development.
Phadke, A., A. Fernandes, L. Sharda, and A. Jesani. 1995. A Study of Supply and
Use of Pharmaceuticals in Satara District. Bombay (Mumbai): Foundation for
Research in Community Health.
Prakasamma, M. 1989. Analysis of Factors Influencing Performance of ANMs in
Nizamabad District. Ph.D. thesis, Jawaharlal Nehru University, New Delhi.
Srivastava Committee. 1975. Report of the Group on Medical Education and Support
Manpower. New Delhi: Government of India.
World Health Organization (WHO). 1961. The Use and Training of Auxiliary Per
sonnel in Medicine, Nursing, Midwifery, and Sanitation. Technical Report Se
ries, No. 212. Geneva: WHO.
239
M. E. Khan • Bella C. Patel • R. B. Gupta
TABLE 12.1
Study coverage: Sitapur District, Uttar Pradesh, 1995
0
K
U
Information from different levels of staff
12 The Quality of Family
Planning Services in
Uttar Pradesh from the
Perspective of Service Providers
• ~~
—
Qualitative approaches used to collect
I
I
■
I
.
■
M. E. KHAN, BELLA C. PATEL, & R. B. GUPTA
fl^gl
2
1
2
In-depth interviews (ANMs)
54
Informal discussions
Chief medical officer
Deputy chief medical officers
Medical officers (doctors)
1
2
8
i
■
:• J
ppc
CHCs
PHCs
Lj Subcenters
Camps
fl
238
Focus-group discussions
Medical officers (doctors)
LHV
ANMs
Observations
■•’-4
There is a growing realization in India that unless the quality of serv
ices in the public sector is improved, acceptance and continuation of
contraception to the desired levels may not be achieved.
It is important to understand the social, physical, and administra
tive environment in which the grassroots components of a health pro
gram function and provide services. Bruce (1990) created a framework
that conceptualizes this environment as program effort consisting of
policy and political support to the family planning program, resource
allocation, and family planning program management and structure.
Given the shortage of essential resources and the problems with facili
ties in many areas of India, providing a high quality of services is a chal
lenging task. In a complex and bureaucratic system like the Indian Fam
ily Welfare Programme, workers at the grassroots level have limited
opportunities to discuss and resolve their problems. They often neglect
their duties by not visiting field areas, not attending clinics, providing
only a limited range of services, or meeting only some of the goals set by
higher officials. Foremost among these goals has been the achievement
of method-specific targets, particularly for sterilization. To improve
the program's services, program managers must take into account not
only the perspectives of users, but also the perspectives of providers.
In this chapter we present health workers' perspectives on the
quality of program services, specifically the readiness of health fa
cilities to provide high-quality services and the obstacles that work-
Number
■---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
■
1
2
10
16
3
ANM=auxiliary nurse-midwife; CHC=community health center; LHV=lady health visitor; PHC=primary
H health center; PPC=postpartum center.
; f'
face in performing their jobs. We discuss providers' views on the
--W1 t-' ers
_____
r___ °
3
need to offer a range of services, to inform clients about................
availablej con1 fc
'
1I traceptives, and to follow up acceptors. We also examine, from the proi viders' perspective, the consequences of over-emphasizing family plan
j ning targets, particularly sterilization targets, for the quality of services.
L
' 11
Data and Methodology
In 1995, using a brief guideline, we conducted a series of focus-group
discussions, in-depth interviews, and informal discussions with 70
health providers in Silapur District, Uttar Pradesh. The research It'.un
I also visited a number of primary health centers (PHCs) and subcenters
to assess their facilities, logistics, equipment, and staffing levels. Dur''
t^ose vis*ts we observed interactions between clients and pro
viders, and, wherever possible, tape-recorded the observations. Each
1
’
member of the research team—an anthropologist, a gynecologist, and
a\
a sociologist—conducted about two months January to March) of in
tensive fieldwork collecting data for the study. Table 12.1 lists the
si:- k .
groups who provided our quality-of-care data.
Sitapur District is located in central Uttar Pradesh, at a distance
fe*’
of 66 kilometers from Lucknow, the state capital. The total popula-
I ?
fr.
J.
■
i
240
Quality of Family Planning Services in Uttar Pradesh
tion of the district, as enumerated by the latest census, was 2.6 mil
lion in 1991, comprising 2 percent of the state's population. Only 12
percent of the district was urban, compared with 20 percent for the
state as a whole. One-third of the district's population is scheduled
castes. Only 17 percent of adult women were literate, compared with
25 percent for all of Uttar Pradesh. Sitapur District is characterized
by very high fertility (a total fertility rate of 5.6 children per woman)
and low contraceptive use (15 percent of married couples). Unmet
need for contraception is estimated to be as high as 42 percent of all
couples (SIFPSA and the Population Council 1994).
The public health facilities in rural areas of the district consist of
19 block-level PHCs and community health centers (CHCs), 41 addi
tional PHCs, and 396 subcenters. Included in the present study are
five block-level PHCs, five new PHCs, and 54 subcenters that fall un
der the administrative jurisdiction of a deputy chief medical officer.
Findings
M. E. Khan • Bella C. Patel • R. B. Gupta
i.
lages because of the lack of educational facilities for their children in
the smaller villages, and also for security reasons. The lack of adequate
transportation and their meager travel allowance made it difficult for
them to cover all the villages in their work areas. Covering each vil
lage on foot was difficult and time-consuming, and spending their
own limited resources for official work was also problematic. Al
though many ANMs maintained that they tried to visit all the vil
lages in their work areas, our observations and discussions with vil;ers indicated that most of the ANMs covered only a few of the
more accessible villages. More distant villages were either completely
mo
neglectedI or visited only during the months of December through
March, when the search for sterilization cases was in high gear. As
one of the ANMs admitted:
g-:
Ir
I:
■ fc;
I• E
| 1381
...
I
'1 F v
Only during camp I visited my entire work area once, along with
my husband, on motorcycle.
■ fe
1
In the sections that follow, we quote extensively from our informants.
In translating their comments into English, we have attempted to pre
serve the flavor of their speech, editing their statements only for clari
fication or brevity.
Two other ANMs commented:
J
Out of 24 villages in my work area, I am hardly able to visit eight to
10 villages every month, 10 to 12 villages once in two months, and
the remaining three to four villages are visited less often (once in
three or four months).
I
Two to three villages are very far (five or six kilometers) [away] and
also not safe enough to go [there] alone. During family planning
camps I told the doctor that I was not able to visit those areas. I le
put two more ANMs on duty to help me so I could cover those ar
eas with them.
■ B
■ SKProblems of Covering Assigned Work Areas
Of the 54 auxiliary nurse-midwives (ANMs) interviewed, only 24 (44
percent) were residing in subcenter villages. The rest were staying
either in larger villages outside their work areas or in nearby towns
or cities. Many were living in the town of Sitapur, the district head
quarters. The distance between nonresident ANMs' homes and their
subcenter clinics ranged from 5 to 26 kilometers. Most of them com
muted from home to their subcenters by bus, motor scooter, bicycle,
horse cart, or truck. Most traveled by foot from the subcenter to other
villages in their work areas, but in cases where the villages were lo
cated in remote areas, the ANMs used a bicycle, motor scooter, or
cart to reach them. Several ANMs reported hiring local boys to take
them by bicycle to the remote villages.
During the focus-group discussions and individual interviews,
the ANMs said they preferred to reside in nearby towns or large vil-
241
61^
8^- -
J
A lady health visitor (LHV), who supervised some of the ANMs,
stressed the problems of distance, mobility, and safety faced by the
ANMs in covering their work areas:
%
al
■
,
I rdI
1
"
Villages are scattered at a distance of four to five kilometers. All the
burden is on her [the ANM] alone. There is absolutely no security
for a female health worker. Even the grant pradhan [elected village
leader] cannot be trusted. There has been a case of rape by him. Un
der such circumstances even if an ANM fails to do her duty at times
or loses interest in her work, I personally do not blame her.
Nearly
Nearly one-fifth
one-fifth of
of the
the ANMs
ANMs we
we interviewed had responsibilf°r 6/000 or more inhabitants (Table 12.2), as compared with the
prescribed norm of 5,000 per subcenter. A majority (61 percent) were
responsible for six to 15 villages, but nearly one-fourth had to cover
quality of i amUy Planning Services in Uttar Pradesh
TABLE 12.2
Numher of villages and combined populations in areas assigned to ANMsoitapur District, Uttar Pradesh, 1995
Coverage
Percentage
Number of villages assigned per ANM
6-10
11-15
16-20
21 +
Total population size of assigned work areas
<5,000
5,001-6,000
6,001 +
Don’t know
(No. of ANMs interviewed)
17
24
37
9
13
54
26
18
2
M. E. Khan • Bella C. Patel • R. B. Gupta
i
3
each ANM had one or two hamlets where she would nut date to go
without a male escort, even during daylight hours. As one medical
r
1i
officer-in-charge told us:
1 |
3 rH
Talking about the widespread insecurity in the area where he
worked, one medical officer described his own situation:
1
(54)
ANM=auxiliary nurse-midwife.
16 or more villages spread over a radius of at least five to six kilome
ters. Given the inadequate transportation and other field problems
facing the workers, covering all the villages in their assigned areas
fe'■i
appears to have been a difficult task. Most of the ANMs confessed
during their interviews that they did not visit remote villages.
The health workers also hesitated to work in certain areas be
cause of the difficulty of working with some caste or religious groups.
Such groups, they explained, did not approve of family planning and
therefore did not want to listen to or cooperate with the workers. Ac
cording to the ANMs, however, the situation is changing and the
ANMs have started gaining acceptance in those areas. As one of the
medical officers put it:
Both the ANMs themselves and the doctors we interviewed menm ""At!!1//631 °f theft' r°bbcry' and sexual violence as a reason for
the ANMs unwillingness to live in their work areas and for not cov
ering all the villages assigned to them. According to the respondents.
I came here from a district hospital about one and a half years back.
I wanted to do things in a better way, [to] understand problems,
and [to] solve them. So when I was posted here, I came along with
all my luggage and [my] family. Once, when I went to Lucknow for
training, my wife was alone at home. Our house was looted in the
night. Now my wife is not willing to stay here. But if I do not stay
here, how can I expect my junior staff to stay here? So I am staying
here with my family despite their opposition.
He added:
I met the district magistrate, police superintendent, etc., and appealed
to them for a license for a rifle. I said, "If you get me a license for a
rifle, then I will stay here." They have agreed to give me a license.
But who [else] will take all these risks? My children are all terror
ized in the evening. Even though the staff is local, they themselves
are afraid.
I
I
LI
11
willing to go [there] in summer. But now TV, radio, and media com
munication are changing their [the villagers'] views. We are also try
ing to reach them Besides, we have started a link person's scheme
for every 20 households. These link workers help ANMs in their various activities.
[The] feeling of insecurity among ANMs is tremendous. So she [an
ANM] always wants [a] companion. This further hinders the work,
as she is dependent on the other person and has to work at his con
venience. During [the] sterilization drive, often they take their hus
bands or someone else to escort them and cover all the areas.
Conditions of the Public Health Facilities
Proper logistic support is crucial if providers are to offer good-qual
ity services. Our visits and discussions with doctors revealed that only
a few subcenters were situated in government-owned buildings. Most
of the clinics were housed in rented or donated buildings, many of
which were inadequate for that purpose.
A medical officer-in-charge of a subcenter commented on the
government's policy of acquiring land for clinics:
II
ID
I
r
•^1
II
The government spends [money] on buildings but not on land. Land
in villages would be available for a couple of thousand rupees. In
stead of spending a few thousands, the government wants free land.
[In some areas] free land is available [only] near the graveyard. Nei....
244
Quality of Family Planning Services in Uttar Pradesh-'”’
ther is the ANM willing to stay there, nor is the client willing to
visit the center or deliver her child in the graveyard. If the govern
ment would spend a few thousand [rupees] extra and purchase land
in the center of a village, then ANMs would stay there.
The absence of a proper space for holding clinics provides a good
excuse for many ANMs not to open the clinics or to provide proper
care, such as conducting physical examinations of patients. Our field
visits revealed that most of the subcenters were functioning in a single
small room with no electricity or toilet facilities. Drinking water, how
ever, was available in all the villages.
Referring to the lack of proper space for holding clinics, an ANM
remarked:
I do not have any proper place to sit or to keep instruments. Where
do I ask them [patients] to sit or where do I examine them? [How]
can I conduct a regular clinic in such a situation?
TABLE 12.3
Supplies of medicines at selected subcenters:
Sitapur District, Uttar Pradesh, 1995______________
——
■ F -
ft-0
■ fc
I
fe-’
■
- &'
Still another ANM said:
■■
We do not even get this amount of 50 rupees regularly. It is paid
after three or four months. During this period either we have to pay
the rent from our pocket or face trouble from the landlord, who of
ten threatens to throw away the goods of the subcenter.
Many subcenters had inadequate supplies of medicine. Most of
the ANMs told us they lacked medicines for treating patients suffer
ing from even common ailments, such as malaria, infection, sepsis,
dysentery, colds, cough, or fever. Even if medicines were provided,
the quantities were insufficient to meet the subcenters' needs. Except
for iron, folic acid, and calcium tablets, other medicines> were largely
unavailable at the 54 subcenters we visited (Table 12.3).
In a focus-group discussion, ANMs made the following obser
vations:
When people ask for medicine and we do not have it to offer them,
they lose confidence in me and think that we are only there to pro
vide family planning services and not other types of health care.
Percentage of ANMs reporting medicines as
Available on
date of interview
Condition requiring treatment
Another complained:
We get only 50 rupees per month for renting a house [to use as a
clinic]. Nowadays how do we get a two-room house for 50 rupees?
Why cannot government provide us a clinic with living quarters?
245
M. E. Khan • Bella C. Patel • R. B. Gupta
k"
I?'
I.
1
I-
Out of stock in
past 6 months
Once More than once
Cold or cough
31
13
7
General fever
24
11
6
Malaria
11
6
2
Infection or sepsis
18
6
7
Diarrhea
37
9
4
Dysentery
(No. of ANMs interviewed)
18
7
4
(54)
ANM=auxiliary nurse-midwife.
We are provided with only iron and calcium tablets and sometimes
paracetamol and antibiotics. Many times we have to prescribe or even
purchase medicines from the market, spending money from our own
pocket just to keep patients happy, especially if she [a patient] is a
potential case for sterilization.
The biggest problem is that we have been provided with no other
medicine except iron and calcium. People complain and almost throw
it back in our face, demanding to know why is it that only red tab
lets and white tablets are given for all the problems. They have al
most lost faith in me and my treatment.
One in three ANMs complained of short supplies of vaccines
(e.g., to prevent measles; tuberculosis; diphtheria, pertussis, and teta
nus; and polio). At the time of our interviews, one-third of the ANMs
reported that those vaccines were not in stock at their clinics. Such
shortages pose a serious problem for the ANMs, who are compelled
to give incomplete series of vaccinations to children. We observed
ANMs inviting women clients to return with their children the fol
lowing week for immunizations, but we do not know how many of
those mothers actually returned, nor whether all the vaccines were
available if they did return.
Having basic equipment in working condition and basic sup
plies is also a prerequisite for providing good-quality services. Al
though 70 percent of the ANMs had an operable blood-pressure (BP)
instrument, which the United Nations Children's Fund (UNICEF) had
recently provided under the Child Survival and Safe Motherhood
246
j
Quality of Family Planning Services in Uttar Pradesh
TABLE 12.4
Availability of equipment and medical supplies at selected subcentersSitapur District, Uttar Pradesh, 1995
M. E. Khan • Bella C. Patel • R. B. Gupta
t
I
Percentage of ANMs reporting
equipment or supplies as
Equipment and supplies
Needles and syringes
Blood-pressure instrument
Stethoscope
Thermometer
Weighing scale for infants
Weighing scale for adults
Available
In working condition
66
76
24
82
74
20
64
70
13
80
19
Examination table
33
24
74
NA
6
2
19
NA
NA
(No. of ANMs interviewed)
(54)
■
63
Nondisposable gloves
Chemicals used for testing
Urine
Blood
Test tubes
I
'
J p
I-
I
13
from both ANMs and LHVs:
ANM=auxiliary nurse-midwife; NA=not applicable.
(CSSM) Programme, only 13 percent had a working stethoscope (Table
12.4). Without a stethoscope, how useful a BP instrument can be is an
open question. Similarly, most of the subcenters lacked an examina
tion table, weighing scale for adults, or reagents for urine and blood
tests. Weighing scales for infants were available and in working con
dition in 34 subcenters (63 percent). Those too had been provided re
cently under the CSSM Programme of UNICEF. Nondisposable gloves
and thermometers in working condition were available in 74 and 80
percent of the subcenters, respectively.
Typical of the comments we heard from ANMs were the following:
For antenatal cases, I would like to record her [the woman's] weight
but there is no weighing machine. I know that [a] urine test to ex
amine albumin is necessary for antenatal cases, but there are no test
tubes or reagents. How do we do [a] urine test?
I have nothing in my subcenter. No table, [no] stool, no bed. There
is one table which is useless. Further, no medicines, no equipments,
no cologne [antiseptic], no pressure cooker or utensils or stove are'
available. What can I suggest for improving the quality of services?
Madam, you are asking about quality of services. Here we have prob
lems in providing even the basic services.
Contraceptive supplies were inadequate or lacking altogether at
most of the subcenters and even at the PHCs in Sitapur District. For
example, according to the ANMs we interviewed, a third of the 54
subcenters we canvassed did not have either intrauterine devices
(IUDs) or IUD insertion kits. Of the 10 PHCs we visited, five did not
have IUDs in stock. In at least three PHCs, condoms or oral contracep
tives were not available. The medical officer-in-charge had no explana
tion for the shortages, merely asserting that contraceptives were always
available to workers except during the end of the fiscal year (March).
Eighteen of the 54 subcenters (33 percent) had both equipment
for sterilizing instruments and kerosene, which is needed to boil wa
ter to sterilize equipment. Thirty had equipment but no kerosene, and
six had neither the required equipment nor kerosene. Thus only a
third of the subcenters were able to sterilize their instruments. Disin
fectants (Cidex, Savlon, and alcohol) were available in only five
subcenters. The following complaints were typical of those we heard
" I
I
I
i
j J
We have to do vaccinations without using spirit. Even if we want to
purchase it from [the] market, we cannot because it is sold only under license.
Kerosene oil is not available at subcenters. We never get a supply.
Although there is an allocation of 30 rupees per subcenter each month
for the purchase of kerosene oil, it never reaches the subcenter. God
knows what happens to it!
Neither disposable (sterile) nor nondisposable gloves were avail
able to a third of the ANMs. Lacking gloves, some ANMs inserted
IUDs without first doing a pelvic checkup. Some did pelvic examina
tions without gloves, but two resourceful ANMs told us they used
condoms for doing pelvic examinations.
ANMs, particularly those who were staying at their subcenters
or in nearby villages, provided assistance in deliveries. Only a few of
the 54 ANMs we interviewed had delivery kits, however. They did
not have even a pair of gloves. Cotton and gauze, needed for immuni
zations, were not available in adequate quantities at any of the
subcenters. Many ANMs spent their own money to buy those supplies.
The following comments suggest that, with adequate support
for their work, the health workers we interviewed could improve their
services:
248
M. E. Khan • Bella C. Patel • R. B. Gupta
Quality of Family Planning Services in Uttar Pradesfe-?^
When a health education officer at one of the PHCs was asked
In the absence of adequate facilities and medicine, the services
provided by the ANMs are optimum. If facilities are improved, we
can think of improving quality of services also.
about this, he had the following response:
We try our best to promote IEC activities, as this is going to be our
only activity. But we have to depend on district or CI IC authorities
for getting vehicles and also VCR [video cassette recorders] and pro
jectors for organizing a video or slide show. They hardly cooperate
or take initiative. What can we do alone, with no support?
Medical officer-in-charge: I feel that the ANMs are doing as much as
they can do. It is unfortunate that no facilities or quarters are pro
vided to them. There are never enough medicines, instruments, or
other essential logistic support for them at the subcenters—not even
for IUD insertion and vaccination.
ANM: The condition of the subcenter should be improved. We should
have equipments like weighing scale, reagents for urine test, blood
pressure measuring instruments, stethoscope, etc. Some medicines,
like calcium, B complex, Methergine, and Ciplin, should also be avail
able to us. Some furniture, such as [an] examination table, table and
chair for myself, should also be provided. I want the people to look
at me as their ANM. I do not want them to think that I am one of the
old dais [traditional birth attendants].
A lack of appropriate information, education, and communica
tion (IEC) materials was another problem. Out of 54 subcenters, only
36 (66 percent) had books, 19 (35 percent) had pictures or posters,
and 3 had a model of the female reproductive organs that could be
used to explain family planning methods to clients. Such IEC materi
als as pamphlets and booklets on family planning and maternal and
child health were available at only one-half of the subcenters for dis
tribution to clients. Seventeen of the subcenters had no IEC materials
whatsoever. Moreover, during our two months of field work we did
not observe clinic staff using any of the available IEC materials. We
were told that this was because most of their clients, being illiterate,
could not read the pamphlets. The ANMs regarded the materials as
useless, and a medical officer-in-charge agreed:
Time Management
B?||
i
te--
A lot of printed materials are wasted. Provide something which is
useful.
■
it
Another medical officer-in-charge noted a problem with the
program's IEC efforts:
IEC activities planned so far have not given any results or signifi
cant impact. The truth is that the BEE [block extension educator, now
called a health education officer] has no role to play. The BEE could
have done lot of things but has not done anything so far. They do
not do any motivational work, while they are assigned a key post to
carry out this activity. This is a frustrated cadre; and as there is no
avenue for any promotion, it does not stimulate them to work.
249
I
i
b
I
To assess how the ANMs managed their time and to what extent they
had enough time to do outreach work, we carefully examined their
work schedules. In discussions with the ANMs and LHVs we learned
that their schedules varied with the season. April was a somewhat
relaxed month, from May to August they were preoccupied with epi
demic control, and from October to March they concentrated on fam
ily planning. When time permitted, they did immunization work.
Maternal care and primary health services were mostly neglected.
An analysis of their schedules revealed that the ANMs wasted a
lot of time in unproductive work. For instance, every Tuesday they
went to the Sitapur District Hospital to collect vaccines, arriving at
about 11:00 a.m. and returning to their clinics with vaccines between
2:00 and 2:30 p.m.; on this day no other work was done. Similarly, on
Thursdays most of them went to Kisan Seva Kendra (a farmers' coop
erative). The purpose was to inform the farmers about family plan
ning and other services available from the PHC or subcenters and thus
motivate them to have small families. In reality, however, the ANMs
had no role in the meetings. Instead, they just sat there for the whole
day and then returned to their clinics. Most did not know why they
were supposed to attend the meetings. As one of the ANMs said to us:
Thursday is the camp day, and if there is no camp I have to attend
Kisan Seva Kendra for three hours. I do not do anything there. People
come from different departments and talk with farmers. But 1 do
not have any role. I never understand why they call me there.
Even those who did know the purpose of attending the meetings
thought they were wasting their time there:
-
During the meeting my duty is to explain about immunization and
family planning to the women. But hardly any women come there,
and if no woman comes then what do I do? Also no one comes from
250
M. E. Khan • Bella C. Patel • R. B. Gupta
Quality of Family Planning Services in Uttar Pradesh
spend] 10 days [at the] PHC. Four days I do vaccinations, four to six
days I spend at the clinic and Kisan Seva Kendra, and four Sundays
and other holidays are [spent] there. In the remaining four to five
days I have to cover all 11 villages.
my department Only [male] farmers come to the meeting. But be
cause it is my duty, I sit there from 10:00 a.m. to 5:00 p.m. If any
officer comes to check [on my attendance], at that time I should be
present there.
We noted a similar misuse of ANMs' time during camp days.
At least one day per week, all the ANMs had to attend sterilization
camps to assist in various activities, whether they had a case or not.
On several occasions during our field visits we observed far more
PHC and subcenter staff at the camps than the number of women
and men who had turned up for sterilizations. On one occasion only
one case was there for a vasectomy, but all 24 ANMs were present.
They had nothing to do with the camp. Instead, all were sitting in a
room, talking among themselves. When we asked the doctor why it
was necessary to call all the ANMs for just one case, he replied:
The schedule of two field days per week is not fixed for the
ANMs. Occasionally a monthly meeting is called on the day normally
reserved for field visits. Sometimes the ANMs go to collect their sala
ries on that day. If they have any personal work to do on that day.
day,
they also postpone their field visits. As one ANM stated.
■
Tuesday, Wednesday, Thursday, and Friday we have [a] fixed sched
ule; hence a field visit is not possible. On Monday and Saturday 1 go
to [the] field according to my convenience and depending on whether
or not I have some ad hoc work.
§
■
Support from Male Workers
When camps start, we divide all the ANMs into four or five groups
to attend different [kinds of] work—one group for OT [operation
theater], one for ward duty, one for clothing, etc. So they have to
come for every camp. We never know in advance how many cases
will be coming on a particular day.
:■
From our observations in the field and discussions with medical offi
■
)
■■
S
During the summer, outbreaks of malaria, cholera, and gastro
enteritis are common. In that season, epidemic work occupies every
one and all other activities are stopped. As a medical officer put it:
Epidemic disturbs the whole work. Every one of us is busy with the
epidemic work. Last year [1994] the condition was quite bad; I have
not seen such a [serious] condition in the last 17 years of my service.
[This situation] demands day and night service, and everyone is busy
with epidemic work.
Family planning activities come to a halt at such times. The fol
lowing comment by an ANM was typical:
During an epidemic, when there is the question of life and death,
how do we talk of family planning and sterilization?
How much time do ANMs actually have for outreach work?
According to the work plan mentioned by the ANMs we interviewed,
they had only two days a week for field visits. As one of them told us:
Frequent field visits are not possible. [Each] month I have to come
to the PHC to collect vaccine for four days, [attend] camp for four
days, and [attend] monthly meeting for two days. In this way [I
J
p
I
I
I
cers, it became clear that ANMs were the key workers at the grassroots
level. Most of the subcenters were managed by the ANMs alone, as the
number of male workers was very limited. Even when male workers
were posted at a subcenter, the ANMs did not get adequate support from
them. Both the ANMs and the LHVs complained that they received neg
ligible support from their male counterparts. According to three LHVs:
Male workers were very helpful earlier. They used to accompany
us to the field. We [female workers] used to get lifts, and in turn the
[sterilization] cases motivated by us were shared by both of us. We
used to cater to antenatal, postnatal, and other cases, and males used
to do their malaria and survey work. But now we have to do our
work all alone.
They [male workers] only go around and order like bosses in meet
ings. Otherwise they do no work, though we have the same portfo
lios [work responsibilities].
The male supervisors project themselves as ex perts and are always
ready to guide us—or order us. They go on buttering the officials
and escape from all work.
Taking the side of male workers, however, another ANM argued.
[A] female worker covers 5,000 to 6,000 population, and [a] male
worker has to cover 25,000 population. How can he help five or six
ANMs at a time? They [the male workers] have their own duty too.
■ I
i i
<
252
Quality of Family Planning Services in Uttar Pradesh
Besides transport problems, there are no pukka [reliable] roads, no ve
hicles, and the distances to be covered are long. They [the ANMs] have
to carry heavy vaccine containers to the field. Male health workers sel
dom accompany them to the field. Most of the ANMs have complained
that they do not get much support from their male counterparts.
Providers' Perspectives on the
Quality of Services
We have to think of the given situation before talking of quality of
services. We cannot turn Sitapur into Miami. People here are poor,
illiterate, and have very low expectations. They have very few basic
needs and do not have high expectations of counseling or informed
choice. They are happy and satisfied as long as they get the [contra
ceptive] method which they desire. We certainly have to improve
our services, but we have to keep in mind the local situation and
sociocultural milieu.
A female worker stated:
We have so much work that we cannot satisfy the clients fully. We
have large populations to cover and [must] move around 20 villages.
During epidemics all of us are busy controlling the epidemic. PHCs
253
and subcenters are full of people, and we have to work day and night.
In such situation how can we satisfy everybody?
A medical officer-in-charge agreed with most of the LHVs and
ANMs that male workers generally did not help the ANMs:
During the interviews we asked health providers to give us their views
on the quality of services being provided at public-sector clinics. In
general, the ANMs appeared satisfied with the services they were pro
viding, although most of them could not define quality of care. Few
could identify gaps in their activities or give suggestions for improv
ing services.
The medical officers-in-charge of the PHCs blamed the lack of
infrastructural facilities and the inadequate equipment, medical sup
plies, and other logistical problems for the clinics' failure to provide
a high quality of services. They also mentioned the poor location of
the subcenter buildings, including safety considerations; the lack of
traveling and living allowances; and the late payment of salaries as
obstacles to improving the quality of services. All three of the medi
cal officers-in-charge felt that discussing the quality of services with
out defining minimal physical, technical, and logistic standards did
not make sense. According to one deputy chief medical officer:
M. E. Khan • Bella C. Patel • R. B. Gupta
I
Technical Competence and On-the-job Training
I •.
following comment, by an ANM, was typical:
When asked whether they needed additional training, most ANMs
indicated their willingness to attend training sessions to strengthen
their skills or improve their performance; but they could not identify
any specific topic or skill area in which they needed training. I he
At our center, I am doing immunization, distributing medicines, do
ing dressings, etc. I provide pills and condoms if they [the clients]
ask for contraception and attend sterilization camps. I am inserting
IUDs alone [without assistance]. During my training I inserted three
or four IUDs. So, if you design my training program for further im
provement of our work, I am ready to attend it. Otherwise I myself
am unable to pinpoint any specific area for training.
■
-.
Another ANM, however, wanted training to improve her "coun
seling skills for better motivation." An LHV mentioned the need for
training in supervision:
II;'
I
If we are given training on how to improve our supervision work, it
will help us in improving <our work and help the ANMs in providing better-quality services.
Some staff told us that the training sessions were often not use
ful or taught the same subjects every time. A general view was that
trainers were far removed from the realities of the villages and that
much of the training could not be put into practice. Those percep
tions were reflected in the following comments made by LHVs dur
ing a focus-group discussion, as well as in comments made during
individual interviews:
? ■
All trainings are the same. What we had learned in 1985 is being
repeated in every other training. It is in fact a waste of 8 to 10 days
and money. If we are given some practical training instead, we will
be more interested.
During the training, they [the trainers] present ideas which are not
at all practical at the field level. For instance, in CSSM training it
was suggested that for each delivery a woman should use new cloth
of about two meters to spread on the floor for avoiding infection.
The poor women are not even ready to spare their used saris for
254
M. E. Khan • Bella C. Patel • R. B. Gupta
Quality of Family Planning Services in Uttar Pradesh
other methods. However, during our field visits we observed that
they did not provide detailed information to their clients about how
specific methods worked, what the possible side effects were, and in
some cases, such as condoms, how a method was used. According to
this purpose. Where will they find 10 to 15 rupees for purchasing
new cloth?
The medical officers-in-charge told us that reorientation train
ing should be critically examined and designed to meet workers'
needs. They felt that in rural Uttar Pradesh, not all procedures pre
scribed in textbooks and training manuals could be practiced. The
trainers who designed the reorientation courses needed to understand
better the realities in the field and teach what could actually be done,
not simply proper procedures in ideal circumstances. These comments
indicate a need for serious thinking on how orientation and training
programs should be restructured to make them more practical, real
istic, and of immediate use to the workers. Unless these issues are
given due attention, health workers will consider training to be "pun
ishment" rather than something useful to them.
Providers'Knowledge of Family Planning Methods
I
I
one ANM:
1
Ji
What is there to tell about condom? We give condom to only those
women who ask for it and know how to use it.
1I
Another said:
This knowledge is natural. We do not have to tell them how to use
condom. Usually one out of every four women asking for condom
is coming for resupply.
■
a
■1 h
-a
Similarly, most of the ANMs interviewed had theoretical and
practical knowledge about IUDs. For example, 42 of the 54 ANMs
said that they inserted IUDs and1 were trained in IUD insertion. Most
of them had received lUD-insertion training, mainly by the LHV, at
their PHCs. In a few cases they had been trained at the CHC by doc
tors. Because most of them had actually inserted only three or four
IUDs during their training, few were confident about their skill in
II
I
■I
Interviews with individual health workers, as well as informal group
discussions and the focus groups, revealed that the providers were
generally well aware of various family planning methods. They also
knew which questions they should ask and which examinations they
should perform before prescribing a method. For example, in the case
of oral contraceptives, an ANM said:
this procedure. As one ANM said:
Didi [the LHV] taught us how to insert an IUD. During training 1 in
serted IUDs in two women. I am not confident to do it independently.
Even today I wait and insert an IUD only in the presence of the LI IV.
[I should ask about] age of the woman and her youngest child, lac
tation status, and menstrual history [date of last menstrual cycle],
and [should] examine her nails, eyes, and tongue to check for ane
mia. If a blood-pressure instrument is available I will check her blood
pressure also; otherwise [I will] ask whether she had any symptoms
or previous history of high blood pressure.
Thirty of the 54 ANMs interviewed had the required equipment
for IUD insertions at their subcenters. Those who did not have the
equipment either shared IUD insertion sets with other ANMs or de
■
On the administration of oral pills they also demonstrated knowledge:
We tell them to take one pill daily in the evening. We also tell them
tliat if she forgets to take [a pill] one day, she should take two pills the
next day. Some women do not wish to take pills on the day of fasting.
In such cases I advise [them] to take two pills on the next day.
The ANMs were able to describe with confidence what they
should ask or tell their clients when instructing them in the use of
ia £:h' -
I
l.r- •
pended on the LHV for IUD insertions.
As mentioned earlier, most of the ANMs did not do pelvic ex
aminations. Among those who did, only a few had gloves and used
them while doing the examinations. If in the course of doing an ex
amination the health workers identified a reproductive health prob
lem, instead of treating the patient or referring her to the PHC or CHC
for treatment, some simply told her that an IUD would not suit her.
Even worse, some ANMs would insert an IUD despite noticing some
indication of a reproductive tract infection (RTI), especially if the
woman was already motivated to accept the method. As one LHV said:
f
256
M. E. Khan • Bella C. Patel • R. B. Gupta
Quality of Family Planning Services in Uttar Pradesh T'*
ents or giving them detailed information about the methods. The fol
lowing comment was characteristic of the ANMs' attitude:
If we do a pelvic check, we find that 75 percent of the women are
suffering from at least one major or minor reproductive health prob
lem, whether [or not] there is any wound or swelling. I still insert
an IUD; otherwise we may lose the case. Who knows whether she
will come back again for an IUD [after she recovers]?
After three or four pregnancies a woman's skin [uterus] becomes
loose and often IUD comes out on its own. What is the point in pre
scribing such women the IUD? To all of them I advise sterilization.
It was therefore encouraging to hear one ANM say:
Cultural biases—especially a preference for sons—also prevented
some ANMs from telling clients about all the methods. For example,
in counseling a woman who was pregnant and had come to the clinic
for an abortion and sterilization, the ANM suggested:
I refer some of the cases with mild or severe reproductive health prob
lems to the postpartum center, the community health center, or the dis
trict hospital before inserting an IUD. To women with minor reproduc
tive health problems, I give iron, folic acid, and calcium tablets.
A majority (33) of the ANMs reported that it was important to
ask women for their medical histories and to do a pelvic examina
tion. Nevertheless, only one-third of them mentioned that it was nec
essary to do a blood test, RTI screening, and urine test before insert
ing an IUD. In most cases, the ANMs did not inform clients about the
side effects of contraceptives. A typical reply was, "We ask women
to come back if they have any problem."
Contraceptive Choice
All the health workers in the group discussions and even during in
dividual interviews agreed with the statement that all contraceptive
methods should be promoted. However, by tailoring their advice to
the presumed need of each client, they missed the opportunity to pro
mote a broader choice of methods. For example, an ANM in a group
discussion was applauded by all the other coworkers when she said:
For newly married couples, we recommend condoms only. After first
child, when she is lactating, we give condoms or motivate for IUD.
If she is not breastfeeding, then we suggest oral pills. After two chil
dren, we motivate them mainly for sterilization.
The worker perceived that she was offering the client method choice
and not emphasizing any particular method. In actuality, however, she
was trying to motivate the client to accept a particular method, depend
ing upon the woman's parity or reproductive status, rather than help
ing her to choose a method from the available contraceptive basket.
During our observation period of several weeks, we seldom observed
an ANM discussing all appropriate family planning methods with cli-
257
!? 81I
[
I
I
Bi
Why don't you continue with this pregnancy? You have only three
go ffor
daughters. See if your next child is a son, and then you can g—
the operation.
Others told us:
We would never ask a woman with only daughters to go for steriliza
tion. A son is required by the family and the society. Who will look
after [the parents] in their old age? Even for couples with one son 1
would recommend sterilization only after the son has completed his
first year. If by God's wish something [bad] happened [to the child], 1
would be in trouble. I myself would feel sorry for the couple.
I mostly recommend the IUD to women with one or two children.
After two children [one of them a son], I motivate them only for
sterilization.
When the issue of promoting a broader method mix was discussed
with the medical officer-in-charge, he had the following comment:
S-i
Our ANMs are attuned to understand that they have to do only ster
ilization work. They are not bothered about any other problem. They
talk and discuss only sterilization. Even with me, they think they
have to talk only of sterilization. I feel if they start promoting spac
ing methods also, they can do better work. But, unfortunately, they
are never asked questions about spacing [births].
When we asked him whether, as the medical officer-in-charge
of the PHCs, he asked ANMs at monthly meetings whether they pro
moted spacing methods, he replied:
I ask, but so what? If I talk of the IUD, they would say that they do
not have apparatus and applicators. It is also true. More than half of
the ANMs do not have kits for IUD insertion. Many times I have
ZD6
Quality of Family Planning Services in Uttar Pradesh
B
reminded higher officials, but I do not know why these are not sup
plied! I can only remind the seniors. Sterilization facilities are also
not adequate. Kerosene is not available many times. How to steril
ize equipments? Theories for improving quality of care and promot
ing method mix are many, but one has to look into practical prob
lems as well.
i-
II
Family planning targets, particularly sterilization targets, were
also mentioned by the ANMs as an important reason for not giving
attention to method mix:
t
i
If one provides all services—antenatal care, postnatal care, and all
family planning methods—but has not achieved this [sterilization]
target, then it means that she has not done anything. So we are com
pelled to put more emphasis on sterilization.
r
1
r
■
ft
I do not think much could be done to revive vasectomy.
If you really want vasectomy to revive, train the doctors in nonscalpel
vasectomy. This new technique may attract males for vasectomy. In
this area all believe that vasectomy is not suitable for males. Women
themselves oppose vasectomy for their husbands. What can the
worker do?
Despite the fact that vasectomy is much simpler than tubectomy,
with a shorter recovery period and fewer side effects, often the com
munity members believed otherwise. In a recent study covering about
five hundred males, probing revealed that a majority of them believed
that tubectomy was simpler (61 percent) and needed less time for rest
and recovery (52 percent) than vasectomy (Khan and Patel 1997). Our
interviews with many doctors posted at the PHCs revealed that they
were not technically prepared to conduct vasectomy operations. Some
who had been trained earlier to perform vasectomies told us they were
out of practice and could no longer do the procedure. Thus, for all
practical purposes, vasectomy is not offered, nor are the doctors
posted at the PHCs trained to do vasectomy or skilled in conducting
vasectomy operations.
Family Planning Targets
We do not force them [couples] or tell them about vasectomy be
cause women believe that the man is the bread earner; and if sometothe f3^6?5 t0 him °r
beC°meS weak' then what wil1 happen
We cannot do much in removing these fears regarding vasectomy be
cause everybody believes it, and these fears are now very deep-rooted.
'
A similar discussion with the medical officers revealed that they
had almost written off vasectomy as a family planning method The
following comments, made during an informal group discussion with
reflect their thinking:
Why spend so much time and energy to remove misconceptions
about vasectomy, when they are so strongly believed by all? With
the same effort, workers can motivate many women for sterilization.
Thus the ANMs offered IUDs and oral pills only to those clients
whom they could not motivate to accept female sterilization. They
did not talk of male sterilization, for several reasons:
Females themselves oppose [vasectomy] because of fear of failure.
Even in the case of genuine failure of vasectomy, females would be
blamed. The women would be accused of conceiving by another man.
About three years back, this happened in this village to an educated
inspector's wife. When she conceived after the inspector was vasectomized, there were a lot of problems and finally the husband un
derwent medical checkup to find out the truth.
about 12 medical officers of PHCs and deputy chief medical officers,
When we asked what the medical officers were doing to encour
age vasectomy, they could not give a firm answer. One said:
■
We do not get any credit for achieving spacing targets, but we get a
scolding for not achieving [our] sterilization target. Sterilization is
also easy for the rural women. They take rest for a week and it is
[done] once and for all. On the other hand, nonterminal methods
are cumbersome, difficult to use in the given social setting, and have
one or the other side effects.
Vasectomy is not at all popular in this region.
M. E. Khan • Bella C. Patel • R. B. Gupta
■ ■
The Indian Family Welfare Programme has adopted a method-spe
cific target approach to reduce the birth rate. The emphasis has been
on numbers of acceptors rather than on the quality of service. The
method-specific annual targets for each state are planned at the cen
tral level in consultation with the respective state governments. The
state governments distribute targets to their districts, which in turn
allocate targets to the PHCs and finally to the workers. In Sitapur
District, each ANM has been assigned an annual target of 36 male
260
Quality of Family Planning Services in Uttar Pradesh
TABLE 12.5
Percentages of sterilization and IUD targets met by 54 ANMs:
Sitapur District, Uttar Pradesh, 1994-95
Method and number of cases
11
iI
; |
Percentage achieved
Sterilizations (target=36 per ANM)
I- 5
6-10
II- 15
16+
38
50
4
8
IUD insertions (target=70 per ANM)
1-20
21-40
41-60
61-80
81 +
5
8
24
36
27
ri-.-.
■
ANM: Why don't you continue with the pregnancy and have a son?
If you still do not want this pregnancy, come after 20 days. We will
261
go to Sidhauli [where there is a CHC] or Sitapur [where the district
hospital is located] for the operation.
Researcher (to ANM): Why did you not motivate her to undergo ster
ilization now?
i i■I
51
ANM: It is possible that she will change her mind and continue with
the pregnancy to have a son and then undergo sterilization. And if
still she does not want the pregnancy and wants to get operated, 1
will get it done after 20 days when the new year starts. I have to
have some sterilization cases for the next year also. This year I al
ready have completed eight cases of sterilization out of a target of
36.1 do not need any more.
-i k
Nearly all the workers complained that they faced major prob
lems in achieving their assigned sterilization targets. Most believed
that competition from workers in the Revenue Department exacer
i fc
ANM=auxiliary nurse-midwile; IUD=intrauterine device.
and female sterilization cases, 70 IUD cases, 200 pill users, and 500
condom users. Each LHV has a target of 24 sterilization cases. In re
ality, the ANMs and LHVs place major emphasis on achieving the
sterilization targets. Few of the ANMs we talked with appeared even
to remember their targets or achievements for IUD and pill accep
tors. To find out, they had to refer to their registers or discuss this
question with other ANMs.
Table 12.5, which presents the percentages of sterilization and
IUD targets met by the 54 ANMs during the year between April 1994
and March 1995, shows that despite the program's emphasis on tar
gets, few ANMs could achieve their assigned target of 36 steriliza
tions and 70 IUDs. In the case of sterilization, nine out of 10 ANMs
had motivated 10 or fewer cases. Only 25 percent of the total steril
ization targets were achieved.
The ANMs and LHVs were aware that higher officials would
not reprimand them if the workers achieved only one-fourth of their
sterilization targets. Because of this general understanding the ANMs
were not motivated to put extra effort into persuading more clients
to accept the procedure. The following exchange, which took place
during one of our observation sessions, illustrates this attitude. A
mother with three daughters who thought she was pregnant came to
an ANM in mid-March for an abortion, to be followed by sterilization.
■
M. E. Khan • Bella C. Patel • R. B. Gupta
t-
■
./
o:
■
■ I
t
I
'itI
J
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I
' r■
bated the difficulty:
I am facing problems because of the Revenue Department workers.
Using provisions under various developmental schemes, they are
able to give much more attractive incentives, like 4 bighas [1 bigha is
roughly one-fifth of an acre] of land or 5,000 rupees for building,
and thereby take away their motivated cases. We cannot provide
these types of incentives. If someone is very poor, then I may give
her one sari, but not more than that.
When asked why she must spend money from her own pocket to induce clients to accept sterilization, the worker replied:
What to do? We have to get sterilization cases. Otherwise we would
be transferred or would not be paid for months. Nowadays all
women who want to have an operation [tubectomy] are getting it
done through the Revenue Department workers because they offer
good incentives. But they do not take M FR [medical termination of
pregnancy] cases. So for an MTP, women have to come to us. Thus
instead of sterilization cases, we are getting mostly MTP cases. Three
out of my five cases are MTP cum sterilization cases.
Another ANM explained:
We serve women right from their second or third pregnancy, take
care of them in their antenatal period, [care for] their newborn, and
go on counseling them for family planning. But they do not listen to
us even after the second or third child. After the fifth, sixth, or sev
enth pregnancy, when they [have] become very weak and again be
come pregnant, then they come to us and say, "Oh, my didi, oh
262
Quality of Family Planning Services in Uttar Pradesh
M. E. Khan • Bella C. Patel • R. B. Gupta
I
mother, now save me from this pregnancy!" Then they are ready
i
to
get sterilized after MTP. This time they have to come to us [for MTPJ.
Otherwise they would go to revenue workers for help and incentives.
Our impression is that the ANMs' search for sterilization cases
was becoming increasingly selective. Many of those we observed
seemed to seek out women with unwanted pregnancies who wanted
to terminate them. A majority of the sterilization cases recruited by
the ANMs were also abortion cases. Many of their clients regarded
induced abortion simply as another family planning method, and the
ANMs appeared to promote that view because it helped them to
achieve their sterilization targets and prevented those women from
going to the revenue workers for sterilization:
•
!
■ 111
I
It
/J
It is very difficult to motivate rural people. After great difficulties I
motivate one or two cases to accept sterilization. However, often on
camp days, instead of coming with me they go through revenue
workers. They [the revenue workers] are giving them land, a house,
buffaloes, and cows under various development schemes. From
where will I [find the wherewithal to] offer them these incentives?
As they [the revenue workers] are giving more incentives, poor
people would obviously like to get operated through them. At times
their husbands tell us that the revenue people are giving incentives
worth 5,000 rupees, and the husbands ask, "What are you giving?"
This year I have only five cases, and I had to spend an average of
1,000 rupees after each case.
At least one-half of the ANMs with whom we interacted agreed
that sterilization targets affected their suggestions to clients regarding
appropriate family planning methods. Because of their supervisors'
emphasis on meeting sterilization targets, the ANMs encouraged all
women with two or more children to be sterilized. In a focus-group
discussion some ANMs admitted that because of the targets they did
not tell the women about the disadvantages of each family planning
method, and they overemphasized the advantages of tubectomy:
I discourage the women with higher parity from accepting IUD so
that they accept sterilization. After the second child or one son, I
only motivate them for sterilization.
Nevertheless, a majority of the ANMs also told us they did not at
tempt to persuade women with contraindications to be sterilized:
■.
If the woman has any serious problem, then we think about her also.
In such cases we never force her [to accept] any particular method.
We have to live and work in the same community. If anything [bad]
happens to her [as a consequence of being sterilized], then we will
only be in trouble.
The targets not only affected client counseling and reduced the
range of methods the providers offered to their clients, but also had a
negative effect on the quality of their work. For example, during ster
ilization camps, we observed at least three cases in which health work
ers operated on women whose hemoglobin levels were less than 10
g/dL, the borderline level for performing the procedure safely. The
workers recorded the levels as 10 g/dL in their records. Workers also
told us they arranged for women with advanced pregnancies to re
ceive abortions followed by sterilization, as well as for women with
pelvic infections to accept IUDs:
•
B-
LHV: Because of our target, if 1 get a patient who is anemic and wants
to have an operation, I will not leave her. I will definitely try to bring
her in for an operation, and as much as possible I will try [to make
sure] that her operation is done.
J
sI
ANM: Many times in case of MTP, even if the pregnancy is more
than three months, we never leave the case because along with M I P
they easily and readily accept the sterilization. Even if the doctors
ask the clients for some money to do MTP at an advanced stage of
pregnancy, we do not bother about that. We pay that money from
our own pocket on behalf of the clients and get the M1 P and steril
ization done.
LHV: Out of 50 IUD cases only 20 women will be found normal af
ter pelvic examination. But because of my target I insert an IUD even
if some discharge or infection is noticed.
■ite
I
I
■'W
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I
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i
I
IL
■
I
i
It is easy for workers to inflate the number of acceptors of
nonterminal methods in their records, and many of the ANMs we
interviewed told us they did so. The following comment was typical:
We do not have any problem in achieving the target for spacing
methods. Whatever number of pills and condoms we were given to
distribute, we distributed that easily.
' When asked how many clients were currently using pills and
condoms, however, they did not know the answer.
r
264
Quality of Family Planning Services in Uttar Pradesh --t
In a focus-group discussion, the ANMs reported that women them
selves demanded spacing methods and came to them for fresh supplies:
Women come for contraceptive resupply, especially on the vaccina
tion day.
During our field visits, however, we saw no evidence of such demand.
Health workers may have exaggerated IUD acceptance as well:
r; F
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3
1 1/
1
it
When we asked the LHVs about the reliability of more than 500
reported cases of IUD insertions in the previous fiscal year, at first
they insisted that those were the figures reported to them by their
ANMs. Upon further probing, one LHV admitted that the actual num
ber of cases may have been only 50. Another LHV added:
■I
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k
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a
Actually I have inserted only four IUDs. But the adhikari [officers]
want updated register and 100 percent achievement of target. That
is why we show 70 to 80 cases in the register.
Then we asked the remaining ANMs about their actual achieve
ment of IUD targets. They admitted recruiting only 30-35 IUD accep
tors. At this point the first ANM intervened, addressing her coworkers:
Nothing is being [tape-]recorded. Now you people can tell the truth.
Researcher: Tell me what happens to the IUDs you have not inserted.
Do you sell them?
ANM: Who will purchase them? What will they do with IUDs?
Researcher: Then what do you do with extra IUDs, condoms, or pills?
ANM: We can't throw them away anywhere, so we bury them.
Another ANM (in a lowered voice): There are many places where we
can still throw them away.
Another ANM: IUD targets are as much emphasized, but the IUD
does not suit everybody and we do not get much time to motivate
cases for IUD. When we go to the village, women are not found at
home. They are on their farms.
■i 1
’• ■’ i was that the ANMs falsely reported IUD acceptance
The implication
in those cases and dumped the IUDs to destroy the evidence.
Later, when we told a higher official about this conversation, his
’■F
rI
response was:
s g?
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JI
A similar picture emerged from our discussion with ANMs at
the CHC. During the formal focus-group discussion, which we taperecorded, all the participants said that they had nearly achieved their
IUD targets. At the end of the discussion we switched off the tape
recorder and started talking with them informally. The women be
came more relaxed and spoke more candidly. When we asked how,
after so much motivational work, the ANMs were recruiting only six
to eight sterilization cases, whereas they could easily recruit 70 to 80
IUD cases, an ANM sitting close to the researcher said:
ANMs were smiling, but no one mentioned fewer than 10 cases:
■'I K
-I K
265
All then revised their numbers of IUD acceptors to 10 or 15. The first
ANM hinted that we were still not getting the correct figure. All the
J5
It is somewhat difficult to convince the women [to accept an IUD],
but once they understand [its advantages] then they accept it easily
and use it for a long period. There is not much problem in achieving
the target for IUDs. Even Muslim women accept this method.
We know that the majority of the cases shown in the records by
ANMs are wrong, but what could they do? They are under pressure
to produce 100 percent result.
M. E. Khan • Bella C. Patel • R. B. Gupta
’
11
Bates -
To some extent we all know about it. This is all because of targets.
Continuity of Care
During the field work, we attempted to assess how much value the
fe'.I •
|
providers attached to following up their family planning acceptors.
In both focus-group discussions and individual informal interviews,
the ANMs and LHVs acknowledged that although they attached great
importance to following up sterilization cases, few of them visited
IUD acceptors, and none of them followedI up pill acceptors.
not only because suFollow-up of sterilization cases is
is required
reqi
tures must
be
removed,
but
also
because
must be removed, but also because community members ex
| Bg
pect the ANM to follow up surgery cases.
cases. The following comments
Ji F '
.
K'-,
I- i fe'
’
i PIfc
were characteristic:
Follow-up of all the sterilization cases is essential. We follow up even
those cases which are motivated by other workers of the Block Of
fice [Revenue Department].
I try to follow up all sterilized cases who are located in close vicin
ity twice, once within three days and the second time after seven or
266
Quality of Family Planning Services in Uttar Pradesh
eight days to cut stitches. If the acceptor is in a remote village, I visit
her only once, on the seventh or eighth day.
We make sure to follow up all sterilization cases. Any complication
after [the] operation could spoil my field. Who will believe me if I
do not try to help a woman in case of complications?
I
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I Ki
j
■a
If we leave the clients without follow-up, next time we will not get a
single case.
b
In contrast, providers followed up very few IUD acceptors, even
those acceptors who lived in the village where the subcenter was lo
cated or in nearby villages. The workers felt no necessity to visit cli
ents at home. In general they advised the acceptors to contact them
in case of complications:
In case of very mild bleeding [spotting], I ask women to come to
me. In case of pain and heavy bleeding, I refer them to the doctor at
the PHC.
I tell IUD acceptors in my work area that as long as one can feel the
thread, it is all right. When you don't feel it, then come and see me.
i ft
fcL
1 ft:
Oral pills have no disadvantage, and in case of any complication
the woman will either come to me or will herself discontinue the
method. So what is the need of follow-up?
Why should we bother if she does not come for resupply? If she has
gone to her parents' house or wants [an] additional child or is suf
fering from side effects, she will discontinue the use of the pill. If
she comes to me, I will also advise the same.
I do not follow up oral pill users. It is not required. Also, if she faces
any problem, she will stop taking it. But there is no major problem
with pills which needs our attention.
We asked the ANMs how many women were still using IUDs,
but they could not give an estimate:
Many women take out the IUD on their own or g
get.........
it taken out, so
how do we know how many are actually using it?
I visit them [acceptors] once in a month for giving them [a] resup
ply. Sometimes for that 1 do not go. I instruct them that before fin
ishing it, they should come and get a resupply.
Similarly, none of the providers could tell us how long, on average,
!
r
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!
Some ANMs suggested that some women spontaneously ex
pelled their IUDs. While discussing IUD follow-up with a medical
officer, we asked him whether spontaneous expulsions were common:
!
Impossible! Even for high-parity women, IUDs cannot be expelled
that way. This is only their [the ANMs'] excuse to save themselves
from being caught for falsifying IUD acceptor cases. It is also posS1 th I*1 sOr^e CaSeS ^at IUDs are not inserted properly by the ANMs,
merely aggravated by the insertion.
We learned that acceptors of oral contraceptives were not followed up. The following comment was characteristic;
h ■
This last statement represented the exception to the usual practice.
Because of the complications, most of the women [seven or eight out
of every 10 IUD acceptors] discontinue it within three to four months.
Despite probing, we could not elicit precise information about
the reasons for the discontinuation of IUD use. Among the frequent
causes mentioned by providers were excessive bleeding, backache,
white discharge, excessive discharge, and swelling. Most of these
symptoms are indicative of improper insertion or infection. It is diffi
cult to assess whether the infections were caused by the IUD inser
tion itself, or whether they had existed before the insertion and were
Most ANMs gave acceptors a month's supply of pills at a time
and expected the women to come back when they needed more:
For follow-up, I call on them after eight days and then after one month.
women used IUDs. The ANMs knew, however, that not many women
continued to use IUDs for extended periods:
M. E. Khan • Bella C. Patel • R. B. Gupta
i
Conclusion
Our study has highlighted several factors that bear directly on the
performance of the health workers and the quality of the services they
provide. It indicates that the public health system lacks a readiness
to deliver quality services. The system's most crucial deficiencies are
the lack of appropriate space for clinics and inadequate equipment
and supplies, such as medicines, serum for immunizations, and even
contraceptives at times. Unless these needs of the PHCs and
subcenters can be addressed, the clinics will have no recourse but to
compromise quality. This does not mean, however, that a major allo
cation of funds is required to improve the quality of services. Never
theless, our findings argue for an increased allocation of resources to
268
< K.,
M. E. Khan • Bella C. Patel • R. B. Gupta
Quality of Family Planning Services in Uttar Pradesh*
bring the clinics up to a minimal level of readiness so that they will
be used by the people.
Lack of transport for workers appears to be the next most seri
ous obstacle to providing outreach services. It demands experimen
tation with various interventions to enhance workers' mobility, such
as providing interest-free loans to enable them to purchase mopeds,
motor scooters, or bicycles. New approaches to workers' assignments
could also improve the situation: Perhaps 25-30 percent of the ANMs'
time could be saved or more effectively utilized by changing their
work routine. Similarly, better logistics would improve the availabil
ity of contraceptives at a number of PHCs and subcenters.
Although we cannot comment on the technical competence of
the workers, our discussions with the doctors suggest that ANMs need
a comprehensive technical reorientation, particularly in IUD inser
tion and counseling skills. As many ANMs pointed out, the training
should be practical rather than theoretical, should simulate actual
working conditions in a rural setting, and should be based on work
ers' needs. The workers do not believe they learn much from the train
ing sessions that are available. According to them, the orientations
either present information they already know or are impractical.
Finally, our findings highlight the adverse consequences of
method-specific family planning targets in the Family Welfare
Programme. The target approach has not only undermined women's
right to make an informed choice of contraceptive method, but also
contributed to an erosion of ethical considerations in providing health
services and, on occasion, serious health injuries to women. Steriliza
tion of anemic women and IUD insertions in women suffering from
RTIs by poorly trained ANMs are just two examples.
The recent initiative by the Indian government to withdraw
method targets nationwide is highly encouraging and, if effectively
implemented, has the potential to contribute to expanded contracep
tive choice and improved quality of care. In contrast, the involvement
of Revenue Department workers in the Family Welfare Programme
is causing major problems for health workers at the PHCs and
subcenters. By offering large incentives to sterilization acceptors un
der various developmental programs, the revenue workers have the
advantage in competing for those cases. One consequence is that
health workers have frequently been forced to recruit their steriliza-
I
tion cases from among pregnant women seeking abortions, with ster
ilization often made a precondition for the abortion. Many states
for example, Karnataka, Maharashtra, and Tamil Nadu—have recently
f
i-
withdrawn the involvement of other agencies in family planning
work. It is time that the remaining states do so as well.
I IM •
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References
■
I K
■■
269
Bruce, Judith. 1990. "Fundamental elements of the quality of care: A simple
framework," Studies in Family Planning 21(2): 61-91.
Khan, M.E. and Bella C. Patel. 1997. Male Involvement in Family Planning: A Knoivledge, Attitudes, Beliefs, and Practices (KABP) Study of Agra District, Uttar
Pradesh. Final report. New Delhi: Population Council.
State Innovations in Family Planning Services Agency (S1FPSA) and the Popu
lation Council. 1994. Baseline Survey in Sixteen Districts of Uttar Pradesh.
Lucknow and New Delhi: Population Council and SIFPSA.
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Part III.
Quality-of-Care Issues
with Sterilization Services
••
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L
13 The Quality of Services at
Laparoscopic Sterilization
Camps in Madhya Pradesh
I
11
i
LAKSHMI RAMACHANDAR & SANDHYA BARGE
<
In 1952 the Indian government adopted a population policy establishing a national family planning program, which it has constantly pur
sued, modified, and expanded. In the 1960s the program began offering
a wide choice of contraceptive methods, and later it introduced an in
centive scheme for both acceptors and service providers (Conly and
.•1
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L
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r
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Camp 1992).
Although the government has always aimed to provide an ar
ray of contraceptive methods, much of the history of the program
has consisted of a series of campaigns focusing on a single method.
The Lippes loop intrauterine device was promoted through intensive
campaigns in the 1960s, and male sterilization (vasectomy) was ag
gressively promoted in the mid-1970s. Public reaction to overzealousness in recruiting acceptors led to a revised policy in 1978 that
stressed the voluntary nature of the program (Conly and Camp 1992).
In the 1980s, the program introduced the laparoscopic technique of
female sterilization, which is simpler and less traumatic than the more
common method of tubal ligation, and today almost a third of all
tubectomies are laparoscopic cases (GOI1991).
The Family Planning Programme (now called the Family Wel
fare Programme) has until recently been target-oriented and contin
ues to focus heavily on female sterilization. A substantial majority of
current contraceptive users have received tubectomies, and a large
proportion of these sterilizations were performed in the public sec
tor. Although district hospitals and community health centers are
273
274
Laparoscopic Sterilization Camps in Madhya Pradesh
Lakshmi Ramachandar • Sandhya Barge
well-equipped and staffed to conduct sterilizations, primary health
centers (PHCs) are not as well-equipped. Moreover, most of the doc
tors posted at PHCs are not trained in sterilization procedures. For
this reason the program periodically organizes sterilization camps run
by experienced doctors who come from district headquarters.
Government officials realize that strengthening the program's
outreach is critical to improving its effectiveness. Hence the organi
zation of the sterilization camps is an annual event between the
months of October and March, when teams of trained gynecologists
visit the PHCs. The main activity of the health workers during those
months is recruiting women to accept sterilization. The camps are or
ganized at various locations in rural areas, and every effort is made to
bring the sterilization services to the doorstep of the rural population.
To gain a better understanding of the quality of services offered
through laparoscopic camps, in 1995 the Population Council under
took a study of camps in five states—Madhya Pradesh, Uttar Pradesh,
Bihar, Gujarat, and Karnataka. The Centre for Operations Research
and Training (CORT), a multidisciplinary research organization in
Baroda, Gujarat conducted the portion of the study in Vidisha District
of Madhya Pradesh, in central India.
TABLE 13.1
Observed laparoscopic camps and cases:
Vidisha District, Madhya Pradesh, 1995
K-
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Objectives and Study Area
The broad objective of the study was to assess the quality of services
provided to clients during laparoscopic sterilization camps. More spe
cifically, the study was designed to assess the quality of sterilization
services offered by the PHCs, subcenters, and outreach program. At
tention focused on the camps' infrastructural facilities, logistic sup
port, manpower, the surgical procedure, and pre- and postoperative
care. The three types of camp were compared on each of these as
pects. The portion of the study reported here included observations
of 82 sterilizations at seven camps in Vidisha District, including one
camp at a PHC, another at a subcenter of another PHC, and the re
maining five in outreach areas of the district (Table 13.1).
Methodology
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Our team of well-trained and experienced social scientists used mainly
qualitative techniques to collect information from the seven camps.
Type of setting
Number of camps
Number of cases
PHC
Subcenter
Outreach camps
1
1
5
19
Total
7
13
50
82
PHC=primary health center.
f
!;•.
275
We observed the entire proceedings of the camps, from registration
to postoperative care, and conducted in-depth interviews with both
service providers and clients. We also engaged in informal discus
sions with clients and providers and held exit interviews with the
clients. With the consent of the providers and clients, we used audio
and visual camera recordings to document our observations.
The research team consisted of six investigators (one male and
five females) headed by a project coordinator (the senior author). The
investigators were given training in what to observe, observation tech
niques, and how to record their observations. Each investigator was
trained in specific functions of the camp and thus was prepared to
observe specific tasks associated with that function. Team members
were also briefed on how to interact with people at the camps. They
were instructed to behave casually in order to avoid causing undue
tension, while executing their tasks efficiently. They were given de
tailed guidelines and a checklist to make sure they collected complete
information.
To observe the proceedings of the camp in their entirety, it was
necessary for the team to be present when daily activities began. Team
members therefore made every effort to arrive at each campsite ahead
of even the sweeper and the paramedical personnel, who were usu
ally the first persons to appear on the day of the camp.
One of the study team members, a trained interviewer, was as
signed the task of collecting background information on the clients
and documenting their individual arrival times. She did this with the
help of a checklist. She also observed the seating arrangements, the
discussions that took place among the providers, and the interactions
between the clients and health providers. She noted such behavioral
cues as body language, facial expressions, and gestures. Another re-
Laparoscopic Sterilization Camps in Madhya Pradesh
searcher was trained to observe the procedure for registering clients:
who registered them, what information was collected at the time of
registration, and how it was documented. A third team member was
trained to observe and document the quality of the preoperative care
provided to clients. This information included the types of services
provided, who provided them, how well the providers performed
those services (e.g., how they conducted precounseling, clinical ex
aminations, and other investigations), and their reasons for rejecting
some clients seeking sterilization. The fourth and fifth team mem
bers were trained to observe the operation theater (OT) arrangements
before and during the surgery. They were to observe and record the
conditions of the OT, including equipment and supplies; the proce
dures used to sterilize surgical instruments and prevent the spread
of infection from one person to another; and the surgical team's
laparoscopic procedures.
Findings
The outreach camps were located 15-50 kilometers from Nateran, the
site of the PFIC. The average distance that the women had to travel
from their villages to the outreach camps was about four kilometers.
Most clients, especially those in outlying villages, were not willing to
travel to tire PHC for their operations. They did not perceive the serv
ices offered by the PHC to be of better quality than those they could
receive at the subcenter or an outreach campsite. The medical officer,
however, found it difficult to arrange logistical support for clients in
outlying areas. Our own observations revealed that the quality of serv
ices, ranging from infrastructural facilities to conditions during and after
surgery, varied considerably across the three types of setting.
Infrastructural Facilities
The Nateran PHC was a cement building with a moderately furnished
OT, which included an OT table, surgical instruments, autoclave, and
emergency kit. The OT had windows with shutters that were closed
at the time of surgery.
The Kamkheda subcenter of Borrow PHC was also a cement
building with two rooms, one of which was used as an OT. Both rooms
A-.--
Lakshmi Ramachandar • Sandhya Barge
were small, and the room used for surgery was dark. Still the room
accommodated an OT table, other surgical instruments, and the lapf aroscope, which was kept on a small table.
At the five outreach areas, the camps were organized in school
buildings. One room of each school served as an OT. The facilities in
the outreach areas were minimal. The makeshift OF rooms had no
shutters or grills on their windows, the flooring was of very poor qual
ity and covered with dust, and there were cobwebs and dust on the walls.
Water and poorly maintained toilet facilities were available in
the PHC but not in the subcenter or the outreach camps. Sweepers
brought water from taps or handpumps 20-30 meters away and stored
it in plastic containers for the use of the doctors and other staff during and after the operations.
Both the PHC and the subcenter had electricity. In the OT, 100/ watt bulbs were used during surgery. In the subcenter, electrical
power was taken from a nearby homeopathic clinic. In the outreach
camps, however, there were no electrical facilities, and lights were
powered by jeep batteries. Additional sources of light were candles
and torches at the subcenter and kerosene lanterns at the outreach
camps. Arranging for proper lighting; was a major problem at the on I
reach camps. Because it was winter, the days were short. The camp
sites were surrounded by thick vegetation,
and it was pitch-dark as
vege
early as 7:00 p.m.
iI
Drawing electricity from the jeeps was a complicated process. It
■ I
-- B
was necessary to use wires long enough to reach from their batteries
to the laparoscope in the OT. Hence some portion of the wires was
hung loosely on the building's pillars or door, or lay on the floor.
When people moved about the room, they would accidentally dis
connect the wires from the batteries or the laparoscope. This happened
every 10 or 15 minutes. Each time the surgeon would shout from the
OT, "Please connect the wires, fast!"
' |h;In one of the outreach camps, the surgeon had completed three
operations, the fourth patient was made to lie on the table, and the
surgical process had started. The surgical team had applied antisep
tic solution, and the surgeon had made a half-inch incision and was
about to insert the laparoscope. But when he picked up the laparo
scope, he found it would not reach the patient. The wire had sud
p7 denly become shorter. He removed his mask and ordered his OT at-
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278
Laparoscopic Sterilization Camps in Madhya Pradesh
Lakshmi Ramachandar • Sandhya Barge
tendants to
push the
IV puon
uie OT table
tdDie closer
Closer to
to him.
mm. They
They had
had difficulty
difficulty mov-’
ing the table with the patient on it. Frustrated by the frequent interruptions of power, the surgeon left the patient and went outside to
find out what had gone wrong and reconnect the wires himself. He
shouted at one of the health providers:
K■
I told you to stand outside and keep an eye on the wires, but where
the hell did you disappear? Do you expect me every time to come
and shout like this?
The extra length of wire had coiled around itself. It was straightened
and the surgery continued. While this incident took place, the un
conscious patient lay on the OT table with her open incision.
In another outreach camp a kerosene lamp burst, throwing the
camp into darkness and scattering broken glass across the ground.
This accident took place close to the OT, where surgery was in
progress. The patient had to be moved to the postoperative room.
The multipurpose worker (MPW) screamed at the male attendant who
was carrying the patient:
B
Ifl
k’
cloth after each operation.
The OT tables were kept in an inclined position. The two legs at
the head of the table were placed on the ground and the other two
legs were
were placed
on aa bench and secured to prevent the table from
legs
placed on
slipping off the bench while the patients climbed onto the table and
I
Transport
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AttendaHt: How long can I carry her? She is too heavy. Please clean
the place fast, she is a dead weight on me. I cannot even go inside
the OT with my slippers.
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PHC vehicles were used in all three settings to pick up and drop off
clients, although about half of the women took buses to the outreach
camps on their own. In the outreach areas a vehicle was used to trans
port the PHC and subcenter staff and materials. One jeep was provided • lusively for the surgeon and‘ his; team to travel between
Bhopal fHiP
(the ranital
capital ritvl
city) and the camps. Dui
During the camps the short
age of vehicles and their poor condition posed a serious problem.
Transporting clients from their homes to the PHC took one to
two hours per trip. This delay caused anxiety on the part of the health
workers. The subcenter had only one jeep available for picking up
and dropping off the clients. The same jeep had to bring the PHC
surgeon and transport OT instruments and other equipment used for
postoperativejcare.
The health provider of the PHC remarked to one of the observers:
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An auxiliary nurse-midwife (ANM) explained the procedure for
maintaining cleanliness:
The tablecloth that is used to cover the OT table is particularly washed
using hot water, and is also soaked in hot water for 10 to 15 minutes.
This has to be done to remove the blood stains and other stains.
The research team observed, however, that the tablecloth was
not changed until all the operations were completed. This procedure
was followed at all the campsites. A lady health visitor (LHV) ex
plained that in a camp situation it was difficult to change the table
to lie down.
,J®: were made......
MPW: Don't come, wait there! I am cleaning the place. There are
glass pieces all over here.
This incident indicates that unless minimal facilities such as a reli
able source of electricity and water are available, an operation or
health camp should not be planned. A power failure complicates the
proceedings and can create a dangerous situation.
The OT teams at all seven camps used spirit or phenyl to clean
the OT rooms and tables. They covered the OT table first with a white
cloth. Over tins they spread a thin mattress and tied the four comers
of the mattress to the four legs of the OT table. The mattress was cov
ered with a mackintosh sheet, and a white, sterilized cloth was spread
on top of the sheet.
279
There is only one jeep, and my colleague has taken the vehicle to
bring cases from her area. My patients will be waiting near the main
road. I had given them a time, and now I do not think I can get them.
By the time the first batch arrives and the time [comesl for fetching
my clients, definitely those women would have left that place. After
my hard work and motivation I have to lose my cases because of
the vehicle problem.
Another ANM expressed her frustration:
i '
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We will get [a] scolding from the clients if we go back tomorrow,
and we also get [a] scolding from our medical officer for our low
achievement and performance. Who is to be blamed in this process?
Am I responsible for this?
260
Lakshmi Ramachandar • bandhya Barge
Laparoscopic Sterilization Camps in Madhya Pradesh
Scheduling Problems and Clients' Wailing I inie
Only one jeep was available for the five outreach camps, and it
had to be pushed from behind before the motor would turn over. At
one of the camps the driver commented wryly:
If this jeep could speak, it would literally cry. We have used this
vehicle to the maximum limit. See the condition of the jeep, the dam
ages caused to it. We have not had time for servicing it, since there
is no replacement and the whole of this month we have camps.
Observing the jeep, the MPW remarked that the lack of reliable ve
hicles was having a negative impact on their recruitment of steriliza
tion clients:
0
y
I would have brought more cases today, but due to this jeep prob
lem 1 have lost so many cases.
As time was running out, the medical officer asked the research team
if they could spare their vehicle to bring clients to the camp.
Manpower
At the PTIC and outreach camps, a surgeon and a medical officer per
formed the sterilizations. All PHC and subcenter staff were also
present, whether or not they had brought their clients. At the
Kamkheda subcenter camp, two surgeons performed the steriliza
tions. The medical officer of the PHC did not attend this camp, as he
was on leave. In all five outreach camps, health providers outnum
bered clients. When the medical officer was asked why so many staff
were called when they were not required to work, he replied:
In an outreach camp we never know when things might go out of
control. Sometimes [the] surgeon does not turn up from the district,
1 have to send a person to contact him over the telephone, or else
[the] jeep breaks down or starts giving trouble. Two men are needed
to push the vehicle. [At the] last minute sometimes we notice that
O F equipments have not arrived, [there is] no kerosene in the stove,
no torch, no candles. Patients sometimes develop complications and
immediate referral has to be done, and a worker has to accompany
the client. Keeping these uncertainties in mind, a large manpower is
needed.
During our observations in the camps, however, none of those prob
lems occurred, and many person-days were wasted.
I
r
At all seven camps the clients arrived in groups, depending on the
availability of vehicles. Most of the clients arrived much earlier than
the health providers. At six of the seven camps the surgeon arrived
late, thereby extending the clients' waiting time. Clients had to wait
an average of four or five hours before seeing a doctor and having
the sterilization procedure. The women had been instructed not to
eat before coming to the camps, so they were both hungry and thirsty.
During the long waiting periods, the health providers made no at
tempt to provide health education or entertainment for the women
and the family members who had accompanied them.
The delay in the doctors' arrival was due not only to their long
commute from Bhopal (50-70 kilometers) but also to their heavy
schedules. They conducted a minimum of three camps per day in dif
ferent locations. If a surgeon was held up at the first camp, the un
foreseen delay affected the subsequent camps as well. Moreover, if a
camp was planned for an outreach area, there was uncertainty about
the timing of clients' arrival and other logistic arrangements. In this stale
of confusion it was difficult to predict when the surgeon would arrive.
The surgeon's delays caused anxiety for the health providers and
even more so for the clients and their families. At one of the outreach
camps the doctor was delayed by more than four hours. The clients
became restless, and some lost their temper and tried to leave with
out having the surgical procedure. At the subcenter, where clients
had been waiting a long time, one woman's husband lost his patience:
Husband (to young wife): I don't think you should keep waiting here.
It is getting too late and I cannot manage the children. Let us go.
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The wife was hesitant about leaving. Her husband walked into the
crowd of women seated on the floor, caught hold of his wife's arm,
and began to drag her away. The LHV tried to detain them.
LHV: Brother, please wait. Surgeon is coming, and I will see that
she gets operated first.
Husband: No, I am not going to wait any longer, and there is no need
for her to get operated.
He walked out angrily with his wife in tow.
282
Lakshmi Ramachandar • Sandhya Barge
Laparoscopic Sterilization Camps in Madhya Pradesh
TT is given to prevent tetanus, Avil and atropine are combined and
given to prevent reactions like palpitations and also to take care of
nervous breakdown and depression.
Program managers should take these problems into account and
try to schedule the clients' arrival at sterilization camps to precede
the arrival of the surgical staff by only a short interval. Staff at the
camps should also do everything possible to reduce the inconvenience
and discomfort to clients caused by unforeseen delays.
If a client had no adverse reaction to the test dosages of zylocaine
and Penidura, she was given a full dose (2 milliliters) of each, the
zylocaine in the arm and the Penidura in the hip. Asked why Penidura
was given in the hip muscles, the ANN! replied:
Registration of Clients and Preoperative Care
When the women arrived at a sterilization camp, they were regis
tered by the block extension educator (BEE) in the case of the PHC
and outreach areas, or by the LHV at the subcenter. The BEE or LHV
collected basic information about the client: her name and her husband's
name, number of children, last child's age, total family income, and
the name of the village where they lived. Other details collected in
cluded her menstrual history and incidence of previous illnesses. At
one camp the BEE was grumbling because he was assigned this work:
Penidura is in a powder form. It is therefore mixed with distilled
water to form [a] 2 milliliter dose, and it is a deep intramuscular
injection. Therefore it is always given in the hip, not in the arm.
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Registration of the clients is not actually my work. Since the LHV
has not come, 1 have been forced to do this work. In our department
we have cooperation but no coordination.
After being registered, a client was examined by the medical of
ficer, who checked her blood pressure and pulse rate, looked for signs
of anemia, and palpated her abdomen. At one outreach camp the
women were also given a blood test and urine test. Next, an ANM
gave the client two injections, 0.25 milliliters each of zylocaine and
Penidura, the second after a five-minute interval. Asked about the
purpose of the injections, an ANM explained:
These two test doses are given to watch out for any adverse reac
tions to the drugs that the patients might develop, like vomiting or
shivering. In those cases who reacted, an antidote had to be given to
counteract the effect. . . . Penidura is a penicillin and an antibiotic.
This will prevent any type of microbial infection either before or dur
ing surgery. This injection can be given at any time. Zylocaine is an
anesthesia, and this injection has to be given at least 5 to 10 minutes
before the surgery. This has to be given only near the naval region.
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This information revealed that the health providers were knowledge
able not only about the purpose but also about the correct adminis
tration of the injections.
Screening of Clients for Eligibility
In all seven camps the medical officer determined that some steril
ization candidates were not eligible because they exhibited symptoms
of certain illnesses. An average of two or three cases were rejected in
each camp. The main reasons were suspected tuberculosis, jaundice,
acute hypertension, anemia, and uterine prolapse. It was encourag
ing to see that even under pressure to achieve sterilization targets,
the surgeons rejected inappropriate cases in an effort to maintain an
acceptable quality of care. The women who were accepted for
laparoscopy at the PHC were an average age of 27 and had an aver
age of 3.6 children, including 1.7 boys. Women in the outreach camps
were, on average, three years older and had one more child.
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Sterilization Procedures for htstrunients
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Other injections that were given as a preventive measure in
cluded tetanus toxoid (TT) (0.5 milliliter), Avil (1 milliliter), and atro
pine (1 milliliter). The research team knew the purpose of those in
jections. As the LHV explained:
283
t
At the PHCs instruments were sterilized in autoclaves and subse
quently kept in trays of hot water. At the subcenter instruments were
sterilized in a pressure cooker and after each operation were soaked
in hot water. Instruments used at the outreach camps were sterilized
at the PHC and carried from there to the campsites, where they were
subsequently kept in hot water. Of the five outreach camps observed,
at least three had an acute shortage of kerosene, used to heat the water.
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Camps in Madhya Pradesh
At the PHC and the subcenter surgical instruments were sterilized
twice, both before and after the surgeon's arrival. During surgery one
of the health providers constantly brought more hot water for the trays
in which the instruments were kept. This precaution was not possible
in the outreach camps. Because the surgeon, who brought the surgical
instruments, invariably arrived at the camps late, there was not enough
time to sterilize the instruments again before surgery commenced.
After each laparoscopy, the laparoscope was dipped in hot wa
ter and wiped with cotton to remove blood stains. Then it was dipped
in Cidex solution for about one second and again wiped with cotton
before being used on the next patient. If autoclaving or boiling is not
possible, tlie recommended procedure for sterilizing surgical instruments
is to immerse them in Cidex solution for at least 10-15 minutes. That
procedure was not followed at any of the observed camps.
When an observer asked the surgeon about this, he replied:
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Besides instruments, the observers paid particular attention to
the way syringes and needles were handled. We were shocked to dis
cover that the surgical teams did not change syringes and needles
between patients. At the PHC and subcenter the needles were changed
after being used on three or four patients, but in the outreach camps
they were not changed at all. Because of the threat of HIV and AIDS,
corrective measures should be taken immediately to prevent this dan
gerous practice.
ii »
Surgical Procedures Inside the OT
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Laparoscopes are very expensive and we do not have more than one
set. So it is difficult to sterilize it for 15 or 20 minutes after each
laparoscopy. Moreover, wiping in Cidex solution is enough to take
care of cross-infection. We prefer not to boil it in water for 10 or 15
minutes; otherwise salt would get deposited and erode the lens.
Inside the OT of the PHC, folded napkins were kept in the auto
clave. Just before the surgery the ANM opened the autoclave, removed
a steaming napkin with the help of forceps, and gave it to the sur
geon. He used the napkin to wipe the patient's abdomen before start
ing the surgery. After using the napkin, he threw it down. For each
new client, the surgical team used a new napkin from the autoclave.
At the subcenter and outreach camps, however, this procedure was
not followed because there was no autoclave.
Tubal rings and surgical instruments were kept in trays filled
with hot water. The water was replaced after every three or four op
erations. The OT staff used aprons, masks, and gloves. In one of the
camps, a male OT attendant used a scarf because there was a short
age of masks. In none of the three types of setting (PHC, subcenter,
or outreach camp) did the OT staff change their gloves after each op
eration. From these observations, it is clear that surgical equipment
and supplies particularly masks and gloves—were inadequate.
Gloves should be changed after each operation because unsterile
gloves can transmit infection from one patient to another.
Lakshmi Ramachandai • Sandhya Barge
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The OT team consisted of at least six persons, including one surgeon,
two LHVs, one ANM, and two male attendants. Team members had
specific
ipecific tasks. One person sterilized the surgical instruments, includ
includ-
ing needles, syringe, scissors, knives, forceps, and tubal rings. At the
surgeon's
geon's command, another pumped carbon dioxide into the
patient's abdomen throughi a small incision. There was little verbal
communication between the surgeon and his staff because all1 were
wearing masks. Most of the time the surgeon communicated through
gestures and eye contact. One person helped the patient climb onto
the OT table and positioned her for the operation. Her head was
placed at the lower end of the table and her hips at the higher end.
In four of the observed camps, the surgeon performed a pelvic
examination before starting the surgery. The LHV cleaned the
patient's abdominal region with antiseptic solution, using long for
ceps and cotton. Next the surgeon made two half-inch incisions, one
on each side of the abdomen. He pushed the laparoscope, along with
the tubal ring that was fixed to its tip, inside one of the incisions. Peer
ing through the laparoscope for a second or so, he located the fallo
pian tube and inserted the ring, then withdrew the instrument. The
instrument was quickly resterilized. The surgeon repeated the pro
cedure, attaching a tubal ring to the other fallopian tube.
One male staff member kept a needle and linen thread ready.
He sutured both incisions and covered the wound with adhesive plas
ter. As with the syringes and needles, the suture needle was not
changed after each operation. At the PHCs, it was simply dipped in
hot water for a few minutes before use. At the subcenter, it was wiped
with cotton and not even dipped in warm water. In the outreach camps.
286
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■fe
the same needle was used for all clients without any attempt to pre
vent cross-infection. The use of linen thread ensured that a health pro
vider would have to follow up with the patients to remove the stitches.
Diazepam, a sedative, used to relieve pain, was administered by
injection to the patient on the OT table after the wound was plas
tered. Fortwin, a pain killer, is recommended for use 10-15 minutes
before the surgery. It was not given, however, and all the patients
were crying from the acute pain of the surgery.
Privacy for Patients
In the PHC the OT had two windows, which were closed during sur
gery. The doors were left open for several reasons. Clients were com
ing in and going out every five minutes, and those who were waiting
for their operations were told to sit near the doorstep of the OT. More
over, the OT instruments were shifted from the adjacent room every
three minutes. The general public was prevented from watching the
surgery from outside, but family members of patients could easily
watch what was happening inside the OT. There was no way for au
ditory privacy to be maintained. Discussions taking place inside the
OT, as well as the screams and moans of the patients, were easily
heard from outside.
At the subcenter it was equally difficult to maintain privacy. The
OT was small, and the doors had to be kept open. Family attendants
waited near the doorstep. It was impossible to close the doors be
cause clients were taken in and brought out every five minutes. The
surgeon's voice and clients' cries were easily heard from outside.
Neither visual nor auditory privacy was possible in the outreach
camps. The windows of the makeshift OTs invariably lacked shut
ters. Sometimes they were curtained to prevent curious onlookers
from peeping in, but in most cases they were not.
Responding to our observer's comment about privacy, a medi
cal officer said:
How can we maintain visual and auditory privacy? It is unthink
able. How can we prevent onlookers [from] watching what is hap
pening inside? All these auditory and visual privacies are needed
only in city hospitals. Here, rural women have accepted the reality,
and they understand that such things are not possible.
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Lakshmi Ramachandar • Sandhya Barge
287
The OT staff made no attempt to protect the patients' modesty
after surgery. The women's petticoats had to be loosened before the
operation could begin, and in a few cases the OT team forgot to retie
the petticoats afterward; in other cases a male attendant was asked
to tie them. When the sedated patients were lifted from the OF table
and carried to the postoperative care unit, their saris were not properly
arranged. Family members who witnessed this, and were able to inter
vene, hurried toward the patients and covered their bodies. Others
watched with helpless embarrassment. The insensitive manner in which
the women were carried by a male attendant or sweeper in the presence
of family members, children, and the general public calls for a greater
effort on the part of the sterilization camps to protect patients' modesty.
Postoperative Care
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After surgery the patients had to be carried to the postoperative care
unit because stretchers were nonexistent even at the PHC and
subcenter. In the PHC the women were placed on a mattress in an
open veranda. At the subcenter they were carried 30 meters away to
a room in the police station. In the outreach areas they rested either in
the open corridor or in one of the other rooms of the school building.
The minimal recommended period for postoperative care is lour
or five hours. This amount of time was not generally possible at the
camps, given the crowded conditions and time of day when the pa
tients arrived at the units. At the PHC, however, patients were given
a choice of remaining there overnight or going home the same day.
According to the PHC's medical officer:
We keep the clients inside one of the rooms. We also give them mat
tresses and blankets. Nearby, there are hotels where the family at
tendants can go and have their night dinner and also get tea or bread
for the patients. Some prefer to stay because they feel there is no
point in reaching the house so late. Hence they stay back.
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The same medical officer remarked:
It is not a joke shifting 19 cases. Now the time is 2:30 p.m. From now
on they are under observation and it will take easily three hours for
them to regain their consciousness. Hence the first shifting will start
only around 6:00 or 6:30 p.m. Dropping the client [in her village]
and returning takes not less than two to three hours per trip. These
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Laparoscopic Sterilization Camps in Madhya Pradesh
Lakshmi Rarnachandar • Sandhya Barge
clients have to be shifted in batches, depending on the location and
distance from where they have come. Now the problem is [that] we
have to drop their family attendants also, and each client has to be
dropped near her house and not on some main road or elsewhere.
He added:
ANM: Madam, our MPW has forgotten to bring the stitch-removal
kit from the dispensary. He has to go back to the subcenter village
and get it. It is hardly 5 kilometers, and can you please give your jeep?
: £■
We will not get [an] additional jeep because everywhere camps are
going on. All medical officers are facing similar problems. Luckily,
government functions or elections have not coincided with our camp'
If it were so, we would have been in trouble because our jeeps would
be withdrawn for election duties.
Many patients, especially those at the subcenter and outreach
camps, were discharged even before they had fully regained con
sciousness. When some of the women were moved to the vehicle to
be taken home, they began vomiting.
Before they were discharged, the women were given 20 TMP
Methoxaprim tablets (four tablets a day for five days), 18 analgesic
tablets (three a day for six days), and B-complex and multivitamin
tablets. No other postoperative advice was given to them.
ANM: How are you?
Client: I am okay, by the grace of God.
ANM: Please lie down on the mattress or on a cot. We have come to
remove the stitches.
Client: I am having too much pain. Please give me medicines, fimiicating the researcher] Is she a lady doctor? Ask her to examine me.
ANM: No, no, she is not a doctor. You please lie down.
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Although the government's official incentive payment for steriliza
tion acceptors is Rsl50, we observed that the clients at the camps re
ceived only Rsl35. Hie camps deducted Rsl5 to cover the cost of fuel
used in transporting them to and from the campsites.
MPW: I left my instrument kit in the ayurvedic dispensary, and now
what shall we do?
ANM: We are in trouble. Who asked you to leave it there? You know
very well we were going to the field for stitch removal, and how
could you forget to bring the kit?
MPW: Please ask madam whether she can give [lend us] her jeep I
will get back within a few minutes with the instrument kit.
Meanwhile the MPW called the client's husband and asked for
a steel vessel and hot water. When the husband brought those items,
the MPW took out a needle, scissors, and blade and placed them in
the hot water. He went outside and washed his hands for at least three
minutes, using soap. Then he took the needle from the vessel and
removed the stitches. He applied boric powder to the wound and cov
ered it with a plaster. The ANM gave the woman analgesic tablets
for her pain.
The team accompanied two male workers on another visit for
stitch removal. On entering the client's house, one of the MPWs be
Patient Follow-up
The observation team accompanied the health providers when they
returned to several outreach areas to remove patients' sutures. The
observers randomly followed up 11 women who had undergone
laparoscopic surgery three or four days earlier. On the day of the field
visit the team accompanied a male MPW and an ANM to a village.
As they arrived, the MPW and ANM had a whispered conversation:
When the MPW returned with the instrument, the group went to a
client's house. Upon entering, the ANM greeted the woman:
gan the conversation as follows:
MPW: Water please, and soap if you have [it]. I have to wash my hands.
j
He went to the tap, washed his hands, using soap, and returned to the
house. The house was dark, and the woman, in pain, was lying down:
MPW: What, there is no electricity?
Client: No, there is no electricity.
MPW: Then what are these [electric] switches meant for, and what
are all these wires meant for?
;t
Client: I don't know, I am having pain.
MPW: Do you have a torch?
Client: We do not keep all those things.
MPW: Do you at least have a candle?
Client: I do not know where it is.
Laparoscopic Sterilization Camps in Madhya Pradesh
290
MPW: Okay, it is not possible to remove the stitches inside the house,
because it is dark and I cannot see the stitches. Why don't you come
out and lie down outside. There is sunlight.
Client: What! Are you going to remove the stitches outside? Every
body will be watching me. You please remove them here.
MPW: No, it is not possible because it is dark.
The client got up slowly, went outside, and lay down on a cot. The
area was partially surrounded by fencing, but neighbors were trying
to see what was happening. The MPW removed the stitches within
two minutes, dressed the wound, and left the place.
In both these cases it was a male worker who removed the
stitches, and the situations in which the procedure took place lacked
privacy. Thus the women's modesty was compromised both at the
sterilization camp and again during the removal of sutures.
The health providers asked the 11 women whose cases we fol
lowed up whether they were having any problems after the surgery.
Almost all of them mentioned backache. Other complaints were of
giddiness and general weakness. Only four of the women reported
receiving counseling at any time during their sterilization experience.
All but three, however, said they were satisfied with the services they
had received. Apparently their expectations were quite low; they had
wanted the procedure, and they got it. The three women who were
not satisfied with the services told our observers they felt they had been
discriminated against because they belonged to lower-caste groups.
They had not been given extra blankets or food, unlike other women.
Lakshmi Ramachandar • Sandhya Barge
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Conclusion
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Our research team observed a total of 82 women sterilized at
laparoscopic camps in three settings in Vidisha District—19 at the
PHC, 13 at the subcenter, and 50 at five camps organized in outreach
areas of the district. From those observations we identified several
aspects of the camps' operations that require attention if the quality
of care provided to sterilization acceptors is to be improved.
The inadequate number of vehicles and their poor condition were
a major program constraint. This was true in all three program settings.
Given the program's emphasis on laparoscopy as a contracep
tive method, the two surgeons qualified to perform this procedure
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were under great pressure. Their heavy schedules caused them to ar
rive at the camps late, creating problems for other camp personnel
and a hardship for the acceptors, who had to wait long hours in dis
comfort. One surgeon routinely performed pelvic examinations as a
preoperative procedure, but the other did not. Prospective acceptors
were given blood and urine tests at only one of the outreach camps.
The surgeons did not have time to sterilize their laparoscopes
between patients. In fact, several of the procedures for maintaining a
sterile environment during surgery were questionable, especially in
the outreach camps. For example, using the same needle and syringe
on more than one patient without properly sterilizing them clearly
could spread infection, with potentially severe consequences, given
the emergence of the AIDS epidemic in India.
The surgeries themselves seemed to be done competently, but other
aspects of patient care were inadequate. In particular, greater effort is
needed to protect patients' privacy—for example, by having female work
ers attend them in the postoperative care unit and handle stitch removal.
Postoperative care was best at the PHC and poorest at the out
reach camps. Patients could stay overnight at the PHC, and the medi
cal team led by the medical officer was there to attend to any emer
gency that might arise. At the subcenter and outreach camps,
however, patients were given only three hours to recuperate before
being transported back to their villages.
Counseling patients before and after the surgery and providing
a visit by the medical officer to the patient's home about a week after
the surgery would go a long way toward improving the quality of
care and client satisfaction. Steps should be taken to improve the
health of those women who are deemed ineligible for sterilization
because of poor health. In short, the welfare of clients should receive
more attention than it does now.
These observations do not imply that staff of the PHC and
subcenter lack the capability or desire to provide a higher quality of
care. In difficult circumstances such as those that exist in the outreach
areas, the best intentions are often defeated by inadequate physical
facilities. All campsites should have water and a reliable source of
electricity. In addition, if sites are selected that have public transport
facilities and space for patients to rest after surgery, the program could
operate more efficiently and provide greater client satisfaction.
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Laparoscopic Sterilization Camps in Madhya Pradesh
The small number of surgeons who are trained to perform
laparoscopies also appears to be a major problem. Other doctors at
the PHCs were reluctant to receive the training for this work because
they feared that they would have to attend the camps and their private
practices would suffer. Perhaps an increase in the level of incentives
would motivate more doctors to get training in laparoscopic procedures.
It is unrealistic to expect sterilization services to be brought to
an equally high level of quality in the three types of setting (PHCZ
subcenter, and outreach camp), given differences in the infrastruc
ture, resource allocation for health care, manpower, and logistics.
Managers may have to focus their attention on the supply system—
that is, on those elements of care that ensure acceptors' access to the
services they need—while striving to offer the highest quality of care
possible within constraints of the existing system. Commitment, lead
ership, and competency of medical officers who are responsible for
PHC and subcenter services are crucial to the effective management
of health care services.
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The Quality of Care
in Sterilization Camps:
Evidence from Gujarat
K-'
DILEEP MAVALANKAR & BHARTI SHARMA
i
References
Conly, S.R. and S.L. Camp. 1992. India's Family Planning Challenge: From Rhetoric
to Action. Country Study Series No. 2. Washington, D.C.: The Population
Crisis Committee.
Government of India (GOI). 1991. Family Welfare Programme in India: Yearbook
1989-90. New Delhi: Ministry of Health and Family Welfare.
14
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Sterilization is the most popular method of contraception in India.
The 1992-93 National Family Health Survey found that of the 36.2
percent of eligible couples using any modern method, most (30.7 per
cent) had been sterilized and only 5.5 percent were using temporary
methods (UPS 1995, p. 143). Sterilization is thus six times more com
mon than all the other modern methods combined. Although the Fam
ily Welfare Programme has begun to give higher priority to spacing
methods than to permanent methods, sterilization is expected to re
main the most popular method for the foreseeable future. Unfortu
nately, the government of India has paid little attention to the qual
ity of sterilization services, and has tended instead to emphasize
achieving targeted numbers of cases. A great deal of demographic
research has been conducted in India, but few studies have focused
on the quality of care in family planning, in particular the quality of
sterilization services (see Shariff and Visaria 1991; Verma, Roy, and
Saxena 1994).
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History of the Camp Approach
to Sterilizations
Although sterilization has been an important component of the Fam
ily Welfare Programme since the 1960sz the camp approach was not
introduced until the Fourth Five-Year Plan (1969-74). Sterilization re
ceived a strong push in the early 1970s with mass vasectomy camps.
293
294
Quality of Care in Sterilization Camps: Evidence from Gujarat
0
H
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Vasectomy
J 51w
Tubectomy
o
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04’56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92
Year
il
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FIGURE 14.1 Acceptors of male and female sterilization: India, 1956-92
Source: GOI, MOHFW, Department of Family Welfare 1996, p. 140.
The chief district administrator (called collector or district magistrate
in India) of Ernakulam District in Kerala successfully brought large
numbers of villagers to camps for vasectomies, thus setting an ex
ample for other regions in the country (Agarwala and Sinha 1983).
This approach spread rapidly, and the prevalence of sterilization rose
by two percent per year. Doctors at the camps tried to outdo one an
other in the number of operations they performed each day, with the
result that there were high rates of failure and other complications.
The Ernakulam camps were models of organizational efficiency,
but their methods were not always duplicated elsewhere. Handling
large numbers of cases placed a strain on the camps' organizational ca
pacity, making follow-up difficult. The number of sterilizations fell as
problems associated with this hurried approach came to light (Soni 1983).
The number of vasectomy cases declined further after 1976, when the
government declared a national emergency during which thousands of
men were coerced to accept vasectomies. Since 1977 female sterilization
has been the most commonly used method (Figure 14.1). Among the 31
percent of couples sterilized as of 1992-93, female sterilization accounted
for 27 percent and male sterilization accounted for a mere 4 percent.
Female sterilization consists of two methods—the abdominal
method, or mini-laparotomy ("minilap" for short), and laparoscopy.
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Dileep Mavalankar • Bharti Sharma
295
which was introduced in the early 1980s. By the end of the decade,
the laparoscopic procedure had become popular because it was quick
and it did not require general anesthesia or a stay in the hospital.
When the procedure was still new, only a few surgeons were trained
in this method, and hence laparoscopies took place in large "camps"
where a single surgeon performed 100-300 operations per day in an
assembly-line approach. The camps were held in any building avail
able. As more surgeons were trained and some of the problems of
such large camps became evident, the camp sizes shrank to 20-50 cases
per day, only occasionally exceeding 100 cases.
Sterilization is the center of what remains a target-oriented pro
gram. The central government sets targets for each state, which the state
in turn distributes to each primary health center (PHC) and worker. In
Gujarat each worker is expected to recruit about six sterilization cases
per 1,000 population, or 18-24 cases per year. The government's fiscal
year begins on April 1 and ends on March 31, which has led to a sys
tem in which the impetus for sterilization recruitment starts in Octo
ber and ends with a crescendo in March. Workers must reach their tar
gets by the end of March or face possible punishment, ranging from a
verbal reprimand to the withholding of their salary or denial of pro
motion. The acceleration of cases can be seen in data from Gujarat and
Maharashtra. In Gujarat during fiscal year 1992-93 about 5,100 steril
izations were completed in April 1992, whereas in March 1993 the num
ber rose to more than 45,000. The data on sterilizations performed each
month in 1993-94 also show that the numbers increase from about 5,000
in April 1993, the beginning of the fiscal year, to a peak of 48,000 in
December and then decline to 37,000 in March 1994 (Figure 14.2). This
periodicity could be due to women's preference for sterilization in win
ter and also to pressure to fulfill targets by the end of the fiscal year.
Maharashtra presents a similar picture: 16 percent of sterilizations took
place during the first quarter of the year (April-June), compared with
33 percent during the last quarter (January-March). Part of this peri
odicity is due to women's preference for having surgical procedures
done during winter months, but the peak of operations in March can
be explained largely by the target system and the pressure workers
feel at the end of the fiscal year to meet their targets. Such pressure has
adverse consequences for the quality of services provided by the camps.
In this chapter we assess the quality of sterilization in camp set
tings, drawing upon Judith Bruce's framework for evaluating the qual-
Quality of Care in Sterilization Camps: Evidence from Gujarat
Dileep Mavalankar • Bharti Sharma
i
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May
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Month and year
FIGURE 14.2 Acceptors of tubectomy: Gujarat, 1993-94
Source: Unpublished information from the Government of Gujarat, Department
of Health and Family Welfare, Gandhinagar 1996.
ity of family planning (Bruce 1990). The sterilization camps provide
an opportunity to observe what information is given to clients, the
technical competence of providers, interpersonal relations, and some
aspects of follow-up. We draw lessons for the national sterilization
program based upon our observations.
1B ■
it
Results
Ik
The Setting and Study Methodology
The study took place in a district in northern Gujarat, the westernmost
state in central India. According to the latest Indian census, Gujarat
had a population of 41 million in 1991. It ranks high economically,
but on a range of social indicators Gujarat ranks considerably lower.
A district is divided into several small blocks called talukas, each
headed by a taluka development officer who is in charge of tire block's
development activities. In Gujarat the laparoscopic camps are organ
ized at a community health center (CHC) or a "mother PHC"_ that
is, an old, large PHC constructed before the new pattern was estab
lished of one PHC for every 30,000 population (instead of for
100,000)—which is usually located at the taluka headquarters. The
sites for camps are generally located in the town where the taluka
has its offices. Camp staffing and management duties arc divided
among the various PHCs of the area by rotation. Throughout the year,
one day of each week is dedicated to sterilization camps. On that day
the operations are carried out from morning to afternoon or evening,
depending upon the number of cases.
This study of sterilization camps covered one PHC and two
CHCs and was part of a larger project assessing microlevel planning
for PHCs. We observed 10 sterilization camps between January and
March 1994. Initially each camp received a visit from a team consisting
of a public health physician, a researcher, and one or two female field
investigators. The team participated in all activities of the camp and
observed the camp's technical, interpersonal, and administrative as
pects. On the basis of these initial observations, we developed a check
list for noting salient characteristics of each camp. Detailed informa
tion about each camp was also recorded in the form of a descriptive
narration. The intent was to assess the quality of the camps and iden
tify areas in need of improvement.
The 10 camps served a total of 275 women. Wc did not observe all
the sterilization procedures, but we spent at least one hour in the op
eration theater (OT) of each camp. We also spent part of our time
observing activities outside the OT. Our attention focused on four
aspects of the camps: (1) the physical facilities of the PHC or CI IC for
camp-related activities, (2) the technical quality of care provided by
the camps, (3) the human quality of care, and (4) organizational and
administrative aspects of the camps.
$|
Physical Facilities
■
£
The most important physical facility at a sterilization camp is the O f.
Other physical features we were interested in observing were patient
facilities and facilities for patients' relatives.
OT. In the PHCs the OT was usually a room that had been tem
porarily converted for that purpose, whereas at the CHC it was gen
erally better equipped. We found the OT at one of the three sites to
be in good physical condition as it had been newly constructed by a
private donor and handed over to the government. At the other two
298
Quality of Care in Sterilization Camps: Evidence from Gujarat
sites (one a PHC and the other a CHC) the OTs were in poor condi
tion owing to improper construction and lack of maintenance. Light
ing and ventilation were also poor; windows did not close properly.
The paint on many walls was old and peeling.
Lack of cleanliness was a serious problem. One CHC's OT had
pigeon nests on the light fixture above the surgical table. None of the
theaters had facilities for scrubbing hands between operations. Al
though wash basins were located outside the theaters, most had no
water; even if they did, the surgical staff did not scrub after each op
eration. Although the general cleanliness of the OT is the most impor
tant aspect of the technical quality of care in sterilization, the unsanitary
condition of the OTs in two of the three centers we observed indicates
the lack of importance given to cleanliness by PHC administrators.
OT equipment was old and in poor condition. There were no
shadowless lamps but only tube lights and modified table lamps with
ordinary bulbs. One might argue that laparoscopy does not require
sophisticated OT lamps, but at three stages of the procedure—mak
ing the incision, closing it, and manipulating the uterus—proper light
ing is essential. At the two CHCs other routine operations were also
done under these circumstances.
Emergency medicines and equipment were lacking at the camps.
For example, although the OTs had oxygen cylinders, the key to open
them, the pipes, and the masks were not readily accessible. No anes
thesia trolley or respirator bag and mask were available for artificial
respiration in the theater. In one of the theaters a blood-pressure (BP)
cuff bulb was being used to pump air into the abdomen, and that
bulb was so tattered that it was being held together with sticking plas
ter. We could find no systematic mechanism for regular inspection
and maintenance of the OT equipment.
Most of the equipment normally found in an OT, such as trol
leys, saline stands, standing BP meter, and the operation table, were
either nonexistent or improvised from wooden furniture. The table
was missing stirrups for arranging a woman's legs in the proper
lithotomy position. The linen was meager and torn, and there was a
shortage of gowns, masks, slippers, and other OT apparel.
The supply of water and electricity was erratic. During our ob
servation at one center, water had to be brought by tanker because
the water pump's motor had burnt out. At the center there was no
running water, so that an assistant had to pour water for the surgeon
Dileep Mavalankar • Bharti Sharma
®'
299
to wash his hands. We were told about operations that had to be susJ?
pended because of the lack of electricity. Twice during the camps we
Br
observed a surgeon having to wait for two to three minutes for interB
rupted power to return while the laparoscope was inside a patient.
Later, when discussing this matter with the district-level officers, we
learned that some years earlier they had run the laparoscope by at
taching it with a cable to a car battery. But this ingenious solution
was
not used in any of the centers we saw.
1
Patient facilities. To make surgery a more comfortable experience
E
requires not only a properly equipped and maintained OT but also
l-Lfacilities for preoperative preparation and postoperative recovery. In
.-Igg
—
——
most of the camps wej observed, attention was not paid to such details. Clean and functioning toilets are essential at a sterilization camp
Il
because, as part of the preoperative preparation, women are given
an enema to empty their bowels. In most camps we observed, the
not functioning properly for lack of water and mainte[MH toilets were
were full of waste.
L ?nanceThere
- Theywere
no systematic seating arrangements for waiting cases.
Women had to sit on the-floor or were kept lying on mattresses after
receiving preoperative medications. At one camp, 35 women clients were
sa
packed side by side on the floor of a small anteroom next to the OT,
waiting for surgery. Overcrowding was less of a problem at the CHCs.
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Patients were not given OT clothes to change into. A woman's
own Niagara (below-waist petticoat) was tied above the breast so that
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it covered her from the breast to mid-thigh. Such exposure must be
J
acutely embarrassing to most women in this culture, where exposure
of women's legs is unacceptable. Patients had little privacy in the rest
O-ing room. Not only were many women crowded into the room, but
|
I
the PHC staff—including male ward boys, peons (untrained male
staff), and doctors—had to pass through it on the way to the OT.
5??.’
Normally women come to the camps through their own means,
but the centers arrange for them to be transported home after sur
gery. The vehicle used for this purpose is a jeep that is usually crowded
with PHC staff, other women from the patients' villages, and patients'
relatives. Therefore the ride home can be quite uncomfortable.
K t?'
The camps provide no food or water for patients, who must fast
J
both before and after the operation. This means that women under
going sterilization have nothing to eat or drink for nearly 24 hours,
beginning the night before their surgery.
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Dileep Mavalankar • Bharti Sharma
Sleriiizaliuii Camps: Evidence from Gujarat
’WHicftfor patients' relatives. An operation is considered a ma
jor event in the lives of Indian women, and therefore they are accom
panied to the sterilization camps by two or three relatives. Many pa
tients have just given birth and so have infants to feed. The relatives
and infant arrive with the patient at around 9:00 a.m. and must stay
until 4:00 or 5:00 p.m. At none of the camps we saw had the authori
ties made any systematic effort to provide them with a shaded place
to sit, chairs or benches, drinking water, or toilets. The relatives had
to wait in the open yard, seeking shade wherever they could find it.
Those with infants made temporary cradles by tying two ends of a
cloth to two supports. Relatives provide much-needed psychological
support to the women who are undergoing the operation, but the PHC
system does not seem to care about their welfare.
Several years ago the Health Department stopped paying work
ers a motivator's fee. Workers told us that, as a result, they had to
spend their own money to purchase tea or snacks for the relatives of
the women they had recruited for the operation. This change was a
source of considerable resentment.
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Technical Quality of Services
The technical quality of care is critical to the overall quality of care
provided by sterilization camps. Poor technical quality can cost lives
and discredit the entire program. We looked at this aspect of quality
during the preoperative, operative, and postoperative phases of care.
Our results indicate that technical quality was inadequate.
Preoperative care. We focused on four elements of preoperative
care: (1) screening and preoperative preparation; (2) the administra
tion of preoperative medication; (3) technical skills of workers; and
(4) patient counseling.
Proper screening identifies and eliminates high-risk cases, and
preoperative preparation reduces risks associated with surgery.
Screening should include a systematic examination to rule out
contraindications for the operation. The preoperative preparations we
observed included a general examination, BP measurement, a urine
test using the Benedict method of measuring sugar level, a blood test
to measure hemoglobin level, shaving of the pubic hair and lower
abdomen, an enema, and the administration of preoperative medica
tions. As already mentioned, patients were required to have fasted
■■■
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1
since the previous night. The general examinations we observed were
cursory and hurried. In most cases a pelvic exam was not done. Hence
in our view the cases accepted for surgery were not properly screened.
The preoperative medications given to each patient included at
ropine (to prevent vasovagal shock), penicillin (an antibiotic), dia
zepam (a sedative), and Phenergan (to prevent allergic reaction). In
all the camps we observed, the nurses were using only about 8 to 10
needles and syringes to inject the four medicines into 20 to 30 women.
The needles and syringes were washed in hot water or sometimes
boiled for few minutes and then reused. Ideally, reusable needles and
syringes should not be reused until they have been boiled for 20 min
utes. There does not seem to be a shortage of supplies—the PHCs
have adequate stocks of needles and syringes given to them under
the Universal Immunization Programme—but the camp organizers
and nurses were not taking the trouble to prepare autoclaved sets of
needles and syringes for the sterilization cases as they normally do for
immunization camps. Moreover, in most cases they allowed too little
or too much time to elapse between the preoperative medication and
surgery, with the result that the medication had not fully taken effect
or the effect had waned by the time the women were operated on.
We observed nurses using the same instrument to give succes
sive patients an enema without disinfecting or even cleaning it. We
could not observe the shaving, but we suspect that the nurses used a
single razor blade on more than one patient. This would have in
creased the risk of transmitting blood-borne diseases, such as 1 ilV
and hepatitis B virus, from one patient to another.
The technical skills of the workers were also deficient. At one
camp we observed, the nurse did not know how to open the vials
properly and accidentally spilled some medicine from each vial. She
even accidentally broke several vials, with the result that the last pa
tients did not receive any antibiotics. In another camp a nurse im
properly attached a needle to the syringe she was using, thereby caus
ing medicine to leak out while she injected a patient. Such incidents
indicate that the staff were not properly trained in preoperative pro
cedures, or they reflect simple carelessness.
After being examined and prepared for surgery, the women were
kept lying in a room until their turn came for the operation. PHC
staff made no attempt at this point to prepare them psychologically
for the operation by telling them what the surgery would entail and
Quality of Care in Sterilization Camps: Evidence from GujarSl
■ hpk-
what they could expect to experience during the procedure. It is pos
sible that the auxiliary nurse-midwife (ANM) had explained this when
recruiting the women at their homes, but this is doubtful. This omis
sion and the other problems described above indicate the weaknesses
of the preoperative preparations.
Quality of care in the OT. The observance of proper OT proce
dures is critical to the prevention of infection and other complica
tions. We found that instrument sterilization was inadequate in all
the camps we observed. The trocar, cannula, scalpel, needles, forceps,
and other instruments used in surgery need to be properly cleaned
and thoroughly sterilized after each use to prevent the transmission
of infection from one patient to another. What we saw instead was
that the trocar, cannula, laparoscope, and scalpel were merely washed
in hot water in a tray after use, dipped in the germicidal solution Cidex
(glutaraldehyde 2 percent solution) for 30 seconds to 1 minute, washed
with hot water again, and reused after being wiped with a sterile
towel. The recommended amount of time for immersion in germi
cidal solution is 20 minutes at or above 25 degrees centigrade for a
high level of disinfection and 10 hours for complete sterilization
(Tietjen, Cronin, and McIntosh 1992). The catgut and needle used for
suturing were cleaned with spirit and hot water, respectively, before
reuse. Instruments used for uterine manipulation were not sterilized
adequately either. Instead of being boiled for 20 minutes, they were
washed with hot water. Surgical staff did not swab each patient's va
gina and cervix or paint them with antiseptic solution before insert
ing the uterine sound, which is required for manipulating the uterus
during sterilization. This omission increased the risk of infection as
cending from the vagina to the uterus and fallopian tubes. Although
skin preparation with antiseptic was done reasonably well, there was
also room for improvement here.
Among the large number of staff present in the OT, only some
wore a mask, gown, or cap. The surgeons and nurses did wear surgi
cal garb, but did not follow general aseptic precautions, such as chang
ing their gloves, gowns, masks, and caps after each operation. After
operating on one patient, the surgeon simply washed his gloved hands
in hot water and dipped them in Cidex before moving on to the second
table, where another patient was kept ready so as not to waste time.
Thus the sterilization of equipment and the aseptic precautions
were extremely inadequate in the camps we observed. No one seemed
i fe
302
303
Dileep Mavalankar • Bharti Sharma
• •
;
i-
to be paying attention to these important details. One positive observation was that, at least at the beginning of a day's surgical activity,
most OT instruments and linen were autoclaved and the color indicator strips were preserved and pasted in a notebook to keep a record
of autoclaving quality. But subsequently the same instruments were
merely boiled or cleaned with hot water and reused.
Supporting our observations of OT procedures at the camps we
visited is a study of 398 PHCs in 199 districts covering most major
states in India, which the Indian Council of Medical Research con
ducted during 1987-89 (ICMR 1991). The researchers observed 2,075
sterilization cases at camps organized by the PHCs. They found that in
40 percent of the cases, sterilization of the instruments was "improper
or not done." They reported that in Gujarat, the laparoscope was not
properly sterilized in 51 out of 65 cases observed, and that the sterilization of other instruments was inadequate in 36 out of 65 cases.
Improper surgical technique increases the risk of complications
’ j surgical technique of the
and failure. We did not observe the
laparoscopy
procedure very closely, as we were not competent to do
lanaroscoov orocedure
so, although an expert gynecologist could tell whether proper surgical
procedures were being followed. In the final analysis, only follow-up
of rates of complication and failure can determine the quality of sui gery. We have not followed up the cases we observed because prop
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erly doing so would have required a prospective study of a large sample.
The attendants in the OTs we observed were not well trained.
Peons served as OT attendants, making mistakes that caused patients
I1
to suffer. In one camp, for example, a peon instructed a patient to
assume? the wrong position, making it necessary for her to get on and
off the table twice. Doing so was difficult because no steps were proy
vided and the table could not be lowered. Nor were the ANMs who
'•
assisted in the operations properly trained to clean the instruments
and disinfect them after each operation. According to one districtI
lOjfe'
level officer, they had been taught some improper techniques during
R
their basic training. Low technical quality of care in the OT could well
KBi ? •be a reflection
- —- of deteriorating
--------------standards ~
in various teaching and tr.intrain
ing institutes in the state.
Postoperative care. After the operation, patients are kept in a room
to
rest
for two hours and then discharged. In one PHC we observed,
I
v
the resting room was very congested. We did not observe any regu'■W ■■
lar measurement of the patients' BP or pulse after the operation. Al-
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121
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j . . Cdic in blei Hizalion Camps: Evidence from Gujarat
ilds is less important now that laparoscopic operations are
done under local anesthesia, it should be done to ensure that patients do
not go into shock as a result of internal injury or allergy to medications.
Follow-up. Patients were given paracetamol and iron tablets at the
time of discharge. But we did not see staff giving them any advice ex
cept such basic instructions as "Don't put water on die wound." No writ
ten instructions were given to the women. The women were delivered
to their homes in a vehicle. The next day the health worker (an ANM or
male worker) or doctor visited each woman at home and inquired about
her health. After seven days the ANM removed the stitches at the
woman's home. We were told that the materials available to the ANM
were not adequate for proper dressing of the wound. Even though fol
low-up is routine, workers have no set protocol for examining the pa
tient; they may miss a developing problem even if they visit the woman.
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Dileep Mavalankar • BharU Shai-iK’
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■
Human Quality of Service
The human quality of service, one of Bruce's six elements for mea
suring the quality of care, is very important because negative impres
sions have an immediate effect on clients' behavior, often causing
them to reject sterilization. For most women who come for the opera
tion, this is their first encounter with hospital services, which include
such unpleasant preoperative procedures as the shaving, enema, and
vaginal examination. Such an experience can be traumatic if there is
little empathy, gentleness, and proper psychological preparation for
the procedures. The provision of good human quality of care requires
training, adequate time, and the right attitude on the part of providers.
Our observations indicate that the PHC system has not given
thought to the interpersonal aspect of the sterilization procedures used
in the camps. The camps are run more or less like an assembly line in
which the surgeon operates on two tables, one patient right after the
other. Generally in this operation the medical officer prepares each
case by painting and draping the patient, then injecting air into her
abdomen. The surgeon makes an incision, inserts the trocar and can
nula, and then inserts the laparoscope and ligates the fallopian tubes.
It takes only two to three minutes for this part of the procedure, after
which the surgeon moves on to the other table. The medical officer
then sutures the wound and puts a dressing on it. At one center we
observed that besides the two patients on the table, two more were
II fe
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I
kept waiting in the OT in a squatting position so that as
patient came down from the operation table, one waiting could immediately take her place. This was done to save the time of the sur
geon, who came from the private sector or from another center. Ap
proximately 10 to 15 operations are done in one hour. In such a setup, it
is not possible to provide much empathetic treatment.
We believe that while waiting for their turn, clients who are next
in line must be frightened by what they see and hear, especially if the
woman being operated on cries in pain—which is common as the op
eration is done with local anesthesia. In one instance we observed,
the surgeon had to do a lot of uterine manipulation because the pa
tient was obese. The woman was crying in pain, and after the opera
tion she began bleeding from the vagina as a result of internal injury
caused by the procedure. Strong painkillers like morphine or pethi-
dine are not given even in such cases.
The division of labor among the lower-level staff has male peons assigned to the OT to help women get on and off the table and to
help them assume the lithotomy position, in which the women's pri
vate parts are exposed. Female attendants are assigned the task of
cleaning the instruments and boiling water outside the OT. In most
camps there are no female doctors, so that male doctors do all sur
gery. Only the nurses who assist the doctors are women. Thus the gen
der allocation of work follows the established hierarchy and is insensi-
tive to clients' cultural modesty.
The nurses we observed did not seem to be sympathetic to the
women. One woman was feeling uncomfortable after being prepared
for surgery and was unable to lie down. She requested water. Instead
of helping or comforting her, the nurse ordered her to "shut up and
go to sleep." No one seemed to pay any attention to the mental con
dition of the clients, whose anxiety might have been alleviated had
they been told, honestly and sympathetically, what to expect during
both the preoperative and operative phases of sterilization. The cli
ents' relatives might have provided some comfort to the women, but
they were not allowed to be with them either before the operation or
afterward until the women were discharged.
The camps made no effort to provide health education or infor
mation to the clients. The women were required to give their consent
for the operation, but it could not be called informed consent. They
were simply told to sign a printed form or, in the case of the large
306
Dileep Mavalankar • Bharti Sharma
Quality of Care in Sterilization Camps: Evidence from Gujarat
number of illiterate women, put a thumb impression on it. Nobody
explained to them what was written on the papers.
Organization and Management of the Camps
I;
„a
!
As mentioned earlier, the sterilization camp is held at one place in the
taluka, usually at the CHC or the "mother PHC." The center's staff are
involved in organizing the camp, but the various PHCs of the areas
where operations are not performed rotate responsibility for staffing
the camp so that all share the burden of work and accountability if
something goes wrong. The medical officers share responsibility for
preoperative examinations and assisting in the OT. The surgeon comes
from the private sector or from a nearby CHC or district hospital. The
peons and ayahs (female attendants) work as OT attendants, and the
ANMs or nurses provide assistance in the OT. Task allocation and overall responsibility are not clearly defined or adhered to. Generally the
PHC sets up four or five stations, one each for registration, preopera
tive examination, preoperative preparation, operative procedures in
the theater, and postoperative rest. Patients are admitted in order of
their place in some sort of queue, but no numbering system is followed.
There was no systematic preparation for the camps we observed,
nor was any thought given to the details of planning and organizing the
camps. No one person had overall responsibility for their management.
There was no monitoring of the various procedures, nor were there
manuals, protocols, guidelines, or standing orders for anything done in
a camp. We found no supervisory checklists in use. Most activities took
place on an ad hoc basis or according to the tradition of a particular cen
ter. District-level health officers came periodically to visit the camps, but
they did not seem to play any role in ensuring a high quality of services.
For example, during our observation period the district-level of
ficer visited one of the camps. Instead of inspecting the various ac
tivities of the camp, he called all the workers and supervisors into
one room and demanded to know who had not achieved their sterilization targets,
laigeuj, lepiiniciiiuiiig
reprimanding those
uiobe who
wiiu iiau
had a siioriidii.
shortfall. Thus
inus insieaa
instead
of helping the camp, he disrupted its activities by diverting staff away
from their respective duties. Likewise, when the taluka development
officer or other higher administrators visited a camp, they were more
concerned about meeting targets than about the quality of care pro
vided or resolving the camp's organizational problems.
Bi' ■
307
Some camps are organized as "prestige camps" in the name of
politicians or top administrative officers of the district, but we found no
indication that the quality of care is given importance even in these camps.
Social service organizations do support tlae camps, but they focus most
of their attention on increasing the number of cases by giving additional
incentives to acceptors rather than on improving the quality of care. For
tunately, during the last few years the additional incentive system has
been discontinued. Nevertheless, there is no indication that camp or
ganizers are paying more attention to the quality of care provided.
Discussion
Bl
I
Our study indicates that although the technology of sterilization is
well established, the quality of services offered in the sterilization
P ■
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camps has to date received little attention. In recent years the Family
>7
Welfare Programme has directed much of its attention to spacing
H
b
methods in response to the criticism that it relied exclusively on ster
IF
IgU'ilization. Consequently, there has been much talk about improving
i
the quality of family planning services, but only in relation to spac
ing methods. This shift to a wider selection of services will take a
time to accomplish. Meanwhile, sterilization will remain the
I fe long
dominant method offered by the program, and therefore the quality
of this important service should be given priority.
The effects of poor quality on the Family Welfare Programme
■3
have not been studied systematically, and future research should con
centrate on this aspect. The literature on business management indi
K'' cates that poor quality may seem effective in the short run, but is costly
over the long term, and that investment in improving quality pays
high dividends. In service management, high quality is regarded as
|
an important asset that can give a provider a competitive advantage
(Berry and Parasuraman 1991).
In the case of sterilization services, poor technical quality can
lead to complications and even death. Poor interpersonal quality can
create tremendous psychological barriers to the use of such services,
and negative impressions of service quality will soon spread fear in
the community. Our mini-survey and in-depth studies done as part
-1
Efe- of the same project revealed that community members had substantial fear and numerous misconceptions about sterilization. Of the 372
women interviewed in the in-depth study, 41 percent believed that
1
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Quality of Care in Sterilization Camps: Evidence from Gujarat
laparoscopy burned the blood or the uterus because it used electric
ity to burn" the fallopian tubes. In focus-group discussions, women
who had undergone laparoscopy made such statements as "My com
plexion has darkened," and "I get black blood during menstruation"
as a proof of "burning" during the operation.
Our survey results also revealed a sizable proportion of
nonacceptors of family planning. The annual target for sterilizations
is around 350-375 per PHC. At one community served by a PHC, we
estimated there were 1,176 couples who did not want more children
but nevertheless had not accepted sterilization; this gap could be de
fined as unmet need. During our in-depth interviews, we probed the
reasons for not accepting this method. Fear alone accounted for ap
proximately 4 percent of the total unmet need for contraception. "Poor
health" and the belief that sterilization caused weakness accounted,
respectively, for nearly 22 percent and 18 percent of unmet need in
two PHCs we studied. Underlying responses like these may be ap
prehension about the operation—apprehension caused by anecdotal
information from clients about the poor quality of services.
The impact of poor quality has been assessed by comparing mor
tality rates following sterilization in the state of Gujarat with those in
developed countries where the quality of care is generally high. Bhatt
(1991) reports that the mortality rate due to sterilization in Gujarat
during 1978-80 was 20.6 deaths per 100,000 operations. In contrast,
in the United States the death rate was only 1.5 per 100,000 hospital
sterilization procedures during a similar time period. Over the years,
sterilization mortality has declined in India and Gujarat owing to im
provement in quality of services. Government data show that between
1990 and 1994, the sterilization mortality rate for India as a whole
declined from 5.5 to 2.2 deaths per 100,000 operations (GOI, MOHFW
1994). Recent data from Gujarat show that sterilization mortality de
clined from 9.1 per 100,000 operations in 1990 to 5.0 in 1994 and then
to 2.0 in 1998 (personal communication. Department of Health and
Family Welfare, Government of Gujarat, Gandhinagar, March 1998).
Thus we have not yet reached sterilization mortality rates that were
prevalent in the United States 20 years ago. Given that in India about
3.7 to 4.3 million female sterilization operations are performed every
year and assuming a rate of 2 deaths per 100,000 operations, there
would be 74 to 86 deaths due to sterilization every year.
Dileep Mavalankar • Bharti Sharma
I-Jr
309
Finally, the fact that health workers face great difficulty in achiev
ing their sterilization targets—which may represent only about 2025 percent of the potential demand among clients to limit fertility—
indicates that many potential clients are reluctant to undergo
sterilization in spite of not wanting more children. A major reason could
be the perceived poor quality of care at sterilization camps. Improving
such quality is within the direct control of the health care system.
11k
11
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!
1 ?•
W/iy Is Quality Poor?
I
I
Why is the quality of care so low in a program of such great national
importance? We previously described eight probable reasons
(Mavalankar 1994):
1. Lack of understanding of the importance of quality of care in the
government system in general. The top managers of the Family
Welfare Programme have not realized the importance of qual
ity of care. The program so far has used a target-incentive ap
proach in which the emphasis is on recruiting acceptors "by
hook or by crook," as a senior program manager put it. And
because the funds for the program come from the central gov
ernment and the targets are determined at that level as well,
state-level officers believe they should be guided by what the
central government directs them to do.
2. Failure to monitor and reward quality. It has been assumed that
because fully qualified doctors perform the operations, they
must be doing a good job. And who outside the medical pro
fession can monitor doctors? Many managers have not recog
nized that standards of medical education have declined and
that the doctors coming into the public system, at least in
Gujarat, are often not adequately qualified.
3. Pressure to achieve numerical targets. At times doctors have had to
compromise their medical standards in response to pressure from
general administrators to meet program recruitment targets.
4. Poor physical infrastructure and equipment. Maintenance stan
dards for all government facilities, including PHCs, have been
declining rapidly. Budget cuts, centrally squeezed allocation
of meager resources, and lack of initiative at the PHC level
mean that the PHCs and OTs are not well maintained.
|
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310
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Quality of Care in Sterilization Camps: Evidence from Gujarat
- :• I
311
5. Deterioration of technical standards in teaching and training institutions.
6. Lack of standards, protocols, manuals, and systematic recording sys
tems. Systems of quality assurance have not been set up in the
program, despite the fact that the government periodically sets
guidelines and issues orders to improve program quality. Most
of the orders seem to remain in the files of the state or district
headquarters and do not get implemented in the field. For ex
ample, since the early 1990s the central government has been
preparing a draft manual on quality of care in the Family Weifare Programme with help from the National Institute of
Health and Family Welfare and the US-based Association for
• Attention paid to critical details and systems set up to record
and monitor them;
• Focus on clients' rather than staff needs;
• Process orientation, not person orientation;
• Follow-up and consistency in approach;
'I
• Use of data for decisionmaking; and
• Teamwork and development of shared values toward high quality.
Given these nine requirements, the program should assess the current
I
situation, develop new standards, and work toward improving quality.
Service quality has to be built into the process and should be a part of
I31||'■ training. It cannot be imposed through mere supervision or inspection.
Voluntary Surgical Contraception. By 1997, however, only
parts of this manual had reached the state and district level,
and its use in the field was not evident.
7. Lack of concern for the human aspects of quality of care.
8. No choice or voice for the clients. Poor people are accustomed to
receiving poor services from all sectors, public and private, and
hence they rarely complain. Perhaps they see no point in com
plaining because they do not believe their complaints would
have any effect. The Family Welfare Programme has no established mechanisms that enable people to have their voices heard.
Researchers have neglected the issue of quality until very recently.
During the last 40 years, most of the research on the Indian program has
focused on demographic outcomes. Programmatic research, operations
research, and health-systems research have received little attention.
Women's groups, who have vociferously protested the introduction of
new contraceptive technologies, are surprisingly silent about the qual
ity of sterilization services. No wonder all is quiet on the quality front.
Unless top management commits itself to developing a high-quality pro
- gram, efforts made at lower levels of the bureaucracy will be futile.
I
In conclusion, sterilization is critical to the success of India's dei®-:;
mographic
and health goals, but the quality of the government's sterw
ilization program must improve if further progress is to be made. Fortunately, there is opportunity for improvement, as the World Bank
Hf arfo many donors are now ready to allocate funds to improve the Family Welfare Programme under the new Reproductive and Child Health
W.
Initiative of the Indian government. It is hoped that this study/ will
fe, encourage many government officers to bring about positive changes
W : in the sterilization program, which remains a central component of
India's Family Welfare Programme.
Steps That Can Be Taken to Improve Quality
hI
Dileep Mavalankar • Bharti Sharma
The literature on service-quality improvement has numerous lessons
for the Family Welfare Programme (Fitzsimmons and Fitzsimmons
1994). The most important requirements for improving quality are:
• Commitment from top management;
• Systematic assessment of quality and rewards for improvement;
• Establishment of a continuous, iterative process of quality improvement with both short- and long-term goals;
pi
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Postscript: A Success Story
■'i ■Si
i In December 1997 we observed a laparoscopic sterilizatiion camp al a
3.3
SB' PHC in the
______
”
“ The
’ meticulous attention
...............that
.
samerTdistrict.
the govern7 ment surgeon paid to the technical
I
quality of care was so surprising
, that
tiiat we thought it merited descripti
description.
f’
The surgeon, a male doctor with
postgraduate qualification in
w
general surgery, came to the PHC from a distant CHC. He is extremely
. careful about surgical aseptic procedures. Moreover, he has adapted
laparoscope to the rural situation, thus improving the quality of
1 fecare and reducing cost. The key quality-improvement features we
S Illi noted at the sterilization camp are described here.
S
---- ----o---- —insists that the OT be wet-mopped and then fumiThe
surgeon
• ^ate^
formalini a day before surgery. No one is allowed inside
P•
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•
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312
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Quality of Care in Sterilization Camps: Evidence from Gujarat
the room until the next day. All the instruments are meticulously au
toclaved, and drums of instruments are prepared on the day of sur
gery. Details of instrument sterilization are recorded. No one is al
lowed inside the OT without a mask and a change of footwear.
Women are screened for diabetes and anemia. Only those with
out sugar in their urine and a hemoglobin level above 8 g/dL are
approved for surgery. The routine examination and preparation are
done as in other camps.
The surgeon has procured five laparoscopes from nearby hospi
tals and CHCs where they are not being used. All the laparoscopes
are properly sterilized in Cidex solution for 30 minutes. After every
operation the used laparoscope is cleaned with boiled water and
dipped in Cidex. The amount of time a laparoscope is dipped in Cidex
is noted. Generally each surgical procedure takes about five or six
minutes; hence with five laparoscopes, the 30-minute cycle works well.
The surgeon waits until the stipulated time has elapsed even if the
operations take less time to complete.
A device designed by the surgeon powers the laparoscope's bulb
when there is no electricity. Three regular flashlight-battery dry cells
and a connector provide the power source. This device ensures that
laparoscopic sterilization continues even when there is a power fail
ure, a common occurrence in most rural areas. The surgeon has also
replaced the light bulb socket of the laparoscope with an ordinary
flashlight socket so that any flashlight bulb can be used to replace the
laparoscopic bulb. A laparoscope bulb is expensive to replace
(Rsl,200) and often cannot be found outside the state capital. A flash
light bulb is much cheaper (Rs2) and is readily available.
Some of the problems observed in other camps were also seen
in tliis camp. They include men working inside the OT to help par
tially exposed women clients climb on and off the table, women hav
ing to wait from morning to evening for surgery, the shaving of pu
bic hair with used razor blades, lack of a proper place or arrangements
for patients' children and other relatives to wait, and the lack of health
education services at the camp. Notwithstanding those problems, the
technical quality of the sterilization procedure is good. The surgeon
has attended the government's quality-of-care training, but our view
is that he is exceptional in implementing the training and going be
yond it. Unfortunately, there is no recognition or reward for such good
IB
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Dileep Mavalankar • Bharti Sharma
work, and no one in the administration has thus far taken note of, or
tried to replicate, his innovations.
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Acknowledgments
We gratefully acknowledge the help and cooperation provided by the officers
of the Gujarat State Health Department and the PHC staff involved in this study.
The study was funded by a grant from the International Development Research
Centre, Canada (No. 88-0295). The writing of this chapter was supported in part
by a grant from the Ford Foundation.
References
Agarwala, S.N. and U.P. Sinha. 1983. "Sterilisation in India," in Population, 3rd
edition. New Delhi: National Book Trust, pp. 128-132.
Berry, L.L. and A. Parasuraman. 1991. Marketing Services: Competing Through Qual
ity. New York: The Free Press.
Bhatt, Rohit V. 1991. "Camp laparoscopic sterilization deaths in Gujarat State, India,
1978-1980," Asia-Oceanic Journal of Obstetrics and Gynaecology 17(4): 297-301.
Bruce, Judith. 1990. "Fundamental elements of the quality of care: A simple
framework," Studies in Family Planning 21(2): 61-91.
Fitzsimmons, J.A. and M.J. Fitzsimmons. 1994. "Service quality," in Service Man
agement for Competitive Advantage. New York: McGraw-1 fill, pp. 188 233.
Government of India (GOI), Ministry of I lealth and Family Welfare (MOI II W).
1994. Annual Report, 1993-94. New Delhi: MOI 1FW.
Government of India (GOI), Ministry of Health and Family Welfare (MOI 1FW),
Department of Family Welfare. 1996. Family Welfare Programme in India Year
book, 1993-94. New Delhi: MOHFW.
Indian Council of Medical Research (ICMR). 1991. Evaluation of Quality of Family
Welfare Services at Primary Health Centre Level: An ICMR Task Force Study.
New Delhi: ICMR.
International Institute for Population Sciences (UPS). 1995. National Family Health
Survey (MCHand Family Planning): India, 1992-93. Bombay (Mumbai): UPS.
Mavalankar, D.V. 1994. Comment on S. Ramasundaram, "Impediments to qual
ity of care," Journal of Health Management 7(2): 58-61.
Shariff, Abusaleh, and Pravin Visaria. 1991. Family Planning Programme in Gujarat:
A Qualitative Assessment of Inputs and Impact. Ahmedabad: Gujarat Insti
tute of Area Planning.
Soni, Veena. 1983. "Thirty years of the Indian family planning programme: Past perfor
mance, future prospects," International Family Planning Perspectives 9(2): 35-44.
Tietjen, L., W. Cronin, and N. McIntosh. 1992. Infection Prevention for Family Plan
ning Service Programs: A Problem-Solving Reference Manual. Dallas: Essential
Medical Information Systems.
Verma, Ravi, T.K. Roy, and P.C. Saxena. 1994. Quality of Family Welfare Services
and Care in Selected Indian States. Bombay (Mumbai): International Institute
for Population Sciences.
Ii1 ?3
7
a•fl K
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John W. Townsend • M. E. Khan • R. B. Gupta
315
TABLE 15.1
; iiij
15 The Quality of Care in the
Sterilization Camps
of Uttar Pradesh
3
Chronology of sterilization camps in India
'I r- ?
1951-56
1956-61
1961-66
1967
1969-74
1974-78
1980-85
Period
IK
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JOHN W. TOWNSEND, M. E. KHAN,
& R. B. Gupta
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Sterilization for men and women is the most commonly used contra
ceptive method both in India at large and in Uttar Pradesh. In Uttar
Pradesh (as well as nationally), three of every four contraceptive us
ers have chosen sterilization, and about 13 percent of all married
women 13-49 years of age have been sterilized. From the beginning
of the public program in Uttar Pradesh in 1956 through 1994, a total
of 8,136,167 sterilizations were performed. During the 1990s, the an
nual number of sterilizations performed in the state has averaged
about 400,000, of which about 13 percent have been vasectomies and
tire remainder tubectomies (GOI, MOHFW1994). About three-fourths
of female sterilizations involve laparoscopy, and nearly all vasecto
mies involve a scalpel incision. No-scalpel vasectomy has only recently
been introduced in India.
In recent decades the number of sterilizations performed each
year has varied widely, depending upon the government's priorities
for the organization of services (e.g., camps or facilities for postpar
tum women) and its policy on outreach and targets. During the 1980s,
for example, the numbers in Uttar Pradesh ranged from a low of 78,438
in 1981 to a high of 751,600 in 1988. Nevertheless, the potential de
mand for sterilization services in the state is considerable. According
to the National Family Health Survey, nearly one-third (31.4 percent)
of married women in Uttar Pradesh want no more children but are
not currently using any contraceptive method (UPS 1994). Even among
^14
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31®*
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Description
No public sterilization service
61 stationary and 16 mobile facilities
Incentives to private physicians; railway camps
Targets set; 1.6 million sterilizations to date (83% vasectomies)
409 mobile clinics, 4,120 stationary clinics; compensation for mortality
Emergency period; 8.3 million sterilizations to date (75% vasectomies)
Laparoscopic method introduced, but not in camps; 4.1 million
sterilizations (14% vasectomies)
1985-90
Mini-laparotomy techniques introduced; 4.1 million sterilizations
(6% vasectomies)
1990-95
2,328 CHCs, 21,254 PHCs identified as potential sites for camps;
introduction of surgical standards
CHC=community health center; PHC=primary health center.
those women who intend to use spacing methods in the future, given
their early childbearing, many will eventually choose sterilization to
prevent additional births.
Public health care in India is designed to be a cascading syshun
Each district, containing about three million people, is served by a
district hospital and a network of community health centers (Cl ICs)
and primary health centers (PHCs). A CHC is a small hospital with
inpatient facilities designed to serve a population of about 100,000. A
PHC is a primary care facility with two physicians and several nurses
meant to serve a population of about 30,000. Postpartum centers
(PPCs), which provide birthing care and family planning services for
postpartum women, may be attached to a CHC or a large PHC. A
camp is defined as any grouping of patients for a specific service, re
gardless of the site or quality. Operationally, even when services are
provided at a health facility such as a PHC or postpartum clinic, the
event is called a camp if either personnel (e.g., surgeons or an anes
thesiologist) or materials (e.g., medicines or equipment) are supplied
externally. In Uttar Pradesh an estimated 80 percent of sterilizations
occur in camps organized by the Ministry of Health and Family Wel
fare (Kumar 1988).
The evolution of camps in India has paralleled the changes and
development of sterilization services over time (Table 15.1). During
the First Five-Year Plan (1951-56), no public sterilization services were
316
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Quality of Care in the Sterilization Camps of Uttar Pradesh
proposed. Although India established an official, centrally sponsored
family planning program in 1952, most of the services were provided
in private clinics and hospitals. By the late 1950s, however, 61 gov
ernment-sponsored stationary clinics and 16 mobile clinics were pro
viding sterilization services. In Uttar Pradesh the first publicly
supported sterilizations were conducted in 1956. The early 1960s
witnessed the introduction of new networks, such as railway dispen
saries for camps, and also incentives to private physicians to provide
permanent contraceptive methods. Mobile services, however,
continued to be emphasized because of the weak public health infra
structure.
In 1967,15 years after the program's inception, the government
set targets for specific methods within the public system. By this time
1.6 million sterilizations had been performed nationally, 83 percent
of them involving vasectomy. In response to explicit method targets,
the number and size of the camps increased dramatically. In Uttar
Pradesh, for example, the number of sterilizations doubled between
1967 and 1968 to nearly 160,000, largely because of this focused ef
fort. The move toward compulsory sterilizations during 1976, pro
moted by the government under Prime Minister Indira Gandhi, saw
the number of cases of sterilization increase to 8.3 million, nearly five
times the number only 10 years before. Family planning targets were
dropped briefly after major public opposition in 1977, but were rein
troduced in 1978. By the mid 1970s 409 mobile services and 4,120 sta
tionary sites were providing sterilizations nationally. With the increase
in volume, the incidence of postoperative deaths also grew, and the
government began to provide compensation to families who experi
enced a death due to surgery.
During the 1970s, vasectomy was still the predominant contra
ceptive method in India, accounting for about 75 percent of all cases.
With the introduction of laparoscopic surgery for women in the early
1980s, the percentage of vasectomy cases fell dramatically, to 14 per
cent nationwide by the mid-1980s. The health system's increasing em
phasis on maternal and infant care narrowed the focus of the Family
Welfare Programme to women as the demographic target group to
reduce population growth. Another innovation in surgical technique
in the late 1980s, mini-laparotomy, reinforced the focus on surgery
for women. Myths and misconceptions grew about vasectomy, so that
hv 1 QQ^
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John W. Townsend • M. E. Khan • R. B. Gupta
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at the national level. In Uttar Pradesh, however, vasectomy still ac
counts for about 12 percent of all sterilizations.
Although the number of sterilizations appears to have stabilized
nationally during the early 1990s at about 4 million per year, the num
ber of potential sites for providing sterilization and follow-up serv
ices has continued to grow, reaching 2,328 CHCs and 21,254 PHCs
by the end of 1994. Despite the large number of potential service sites
in Uttar Pradesh (213 CHCs and 3,716 PHCs) in 1994, only 41 percent
of the PHCs had the necessary equipment and facilities to provide
sterilization services, and only 14 percent of the state's medical offi
cers had been trained to provide surgical services. The introduction
of no-scalpel vasectomy in 1990 marked the first innovation in male
contraception in nearly 40 years.
Only in 1991 did the Ministry of Health and Family Welfare pro
mulgate standards for care (GOI, MOHFW 1991, p. 4). Previously it
had issued guidelines but placed much reliance on the skill of individual surgeons and camp organizers. Standards impose a higher level
of demand on the system and begin to shift the focus from the number
of cases to system readiness and quality. Camps have also changed in
size over time. During the early years of the program, it was common
for several hundred operations to be performed during a single camp,
and surgeons often boasted about the large number of sterilizations they
had performed. More recently, camps have become smaller, and a larger
number of sites has been used to increase the accessibility of services.
The percentage of eligible couples sterilized has risen with time,
not only because of the cumulative effect of sterilization acceptance,
but also because the demand for limiting births continues to be high.
According to the government's management information system, in
Uttar Pradesh between 1988 and 1992 the percentage of couples ster
ilized rose from 17 to 20 percent. The rise in percentage sterilized in
urban districts, such as Kanpur, was more rapid (from 18 to 26 per
cent) during that period, while the rise in rural districts, such as Sitapur,
kept pace, but at a lower absolute level (from 15 to 18 percent).
Annual targets for Uttar Pradesh have varied in the 1990s from
650,000 to 820,000, but the achievement of state-level targets has never
exceeded 60 percent in recent years. Target achievement has varied
dramatically among state districts, moreover, ranging from 11 per
cent to more than 136 percent. In districts designated as target-free in
1QQS
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arhipxzprnpnfc for cf-orili'rcjf-ionr
OQ
318
cent in Sitapur to 61 percent in Agra, where the targets were approxi
mately 13,600 sterilizations for populations of about 2.8 million each.
Moreover, in recent years about 34 percent of annual vasectomy cases
and about 17 percent of annual tubectomies in Uttar Pradesh have been
performed during the last month of the fiscal year (March), when pres
sures to improve the level of target achievement are often intensified.
How the Public Sector Recruits
Sterilization Cases
and Provides Its Services
. I
sl
o
Quality of Care in the Sterilization Camps of Uttar Pradesh
Most sterilization services in Uttar Pradesh are conducted in the public
sector (93 percent for females and 95 percent for males), and there
fore the quality of public-sector services is the logical focus of analy
sis. The usual sites for sterilization camps are hospitals (about 60 per
cent) and PHCs (35 percent). Only 5 percent of sterilizations are still
provided through mobile services. In the past, schools and other pub
lic buildings were sometimes used for camps, but because they were
unlikely to have adequate facilities, the use of these sites has been
gradually discontinued.
Both health and development-sector staff recruit sterilization
cases, but sterilization services are the responsibility of the Ministry
of Health and Family Welfare, regardless of the setting. Within the
development sector, recruitment is handled by community develop
ment workers, who report ultimately to the district magistrate, the
most senior government administrative authority within a district.
Within the health system, the auxiliary nurse-midwife (ANM) and
the male multipurpose worker (MPW) have principal responsibility
for recruiting sterilization cases at the village level. Since little coun
seling is provided in the camps themselves, camp administrators as
sume that
F
those two entities, the community development workers
and the ANMs and MPWs, provide the information clients need for
making an informed choice. They also assume that the health system
provides the training needed by ANMs and MPWs for proper fol
low-up. However, clients recruited and brought to the camps by de
velopment personnel are less likely than those recruited by health
personnel to have undergone adequate screening and counseling.
Moreover, development staff are more likely to induce prospective
clients to accept sterilization bv tellin? them about monetarv incen-
John W. Townsend • M. E. Khan • R. B. Gupta
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319
tives, which they disburse. In 1994 the government of Uttar Pradesh
allocated one-half of the targets for sterilization to nonhealth person
nel in development agencies, rather than to health system staff.
In theory there is nothing inherent in a camp setting that limits
the quality of care, as clients should receive counseling about avail
able methods and their options before they arrive at a camp. In Tamil
dia
Nadu, for example, a women's health-advocate group provided d
phragms in a camp setting after providing extensive community edu
cation about contraceptive options, potential benefits and risks of
method use, and follow-up (Ravindran 1995).
Ik ; Quality of Care as Measured
1 |gy.-J
■1
by Camp Infrastructure and
Staff Competence
community education is of considerable interest, this chapI Hl T Although
ter
ter does
does not
not focus
focus on
on that
that aspect
aspect of
of the
the quality
quality of
of sterilization
sterilization serv-
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ices in Uttar Pradesh. Rather, it examines two elements of quality that
are under the control of camp organizers and surgeons: the readi
ness of the camp infrastructure to provide a standard quality of serv
ice and the technical competence of providers and their staff.
Data
We draw upon several sources of data. The first is the 1992-93 National Fami,y Health Survey (NFHS), which posed a set of questions
to a nationally representative sample of women who had undergone
sterilization prior to the survey. The second is research conducted by
the Indian Council of Medical Research (ICMR 1982, 1991) on sterilization and quality of care in Uttar Pradesh. The third consists of pri—. J ~
___ 1
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mary
data collected
by
a team of Population
Council
consultants
ing participant-observation techniques at three sterilization camps in
Sitapur District in March 1995 (Gupta 1995). The Population Council
team also conducted interviews with providers in the three camp settings: a PPC, a CHC, and a PHC. They observed some 30 women un
dergoing sterilization procedures, approximately 10 at each site. Five
other women who sought sterilization were denied the service because of contraindications detected during preoperative examinations. •
The data from these three sources arp infprwnvpn in fhp fnllniA7in(T
I
320
I'H
Quality of Care in the Sterilization Camps of Uttar Pradesh
TABLE 15.2
Clients’ reports of problems with sterilization:
Uttar Pradesh, National Family Health Survey, 1992-93
J E '
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1 ■
Percentage reporting problems related to
Problem
One or more problems
Pain or backache
Weakness or inability to work
Fever
Sepsis
Failure; women became pregnant
Loss of sexual power
Other
No problems •
(No. of clients)
Female sterilization
Male sterilization
28
20
10
11
7
3
1
<1
<1
4
72
(1,287)
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• '1
1
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4
2
<1
<1
1
89
(151)
Source: UPS 1994.
iI II■
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section to provide a more comprehensive picture of the quality in
camps in Uttar Pradesh.
1I r
Results
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John W. Townsend • M. E. Khan • R. B. Gupta
First, a few facts about acceptors of vasectomy and tubectomy in Uttar
Pradesh. They had an average of 3.8 living children in 1991, about 0.5
children more than the national average. The average age at which a
woman receives a tubectomy in Uttar Pradesh is 32.8 years, three years
higher than at the national level (GOI, MOHFW 1994).
Few data exist on the quality of sterilization services in Uttar
Pradesh as perceived by female acceptors, but the NFHS asked women
who had undergone sterilization about the problems they subse
quently experienced. Whereas only 11 percent of vasectomy accep
tors reported one or more problems, nearly 28 percent of women ex
perienced one or more problems following tubectomy (Table 15.2).
The most common complaint in both types of sterilization was post
operative pain or backache (20 percent for women and 7 percent for
men). The second most common complaint was weakness or inabil
ity to work (10 percent for women, 4 percent for men). Given that
women's work is central to the welfare of most families, a woman's
inability to work even for a day or two can be a major family prob
lem. Women considering the operation for themselves understand
ably pose such questions to health workers as "Who will care for my
children?" and "Who will prepare meals and dn fhn wnrl in fho GnMc?"
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Their fears about sterilization are not unfounded. The Indian
Council of Medical Research (ICMR) (1982) found that one month <il
ter the operation, pelvic infections afflicted 15.5 of every 1,000 Indian
women undergoing the procedure, and 84 of every 1,000 women re
ported problems with the wound. As with any major surgical proce
dure, sterilization carries with it mortality risk. According to the same
review, mortality rates among postoperative women were 6.2 per
10,000 for sterilizations unaccompanied by a birth or abortion, 3.3 per
10,000 for postabortion sterilizations, and 0.7 per 10,000 for postpar
tum sterilizations (ICMR 1982). Most sterilizations performed post
partum or postabortion are conducted in PPCs, where staff and la
cilities are generally better prepared and equipped than elsewhere to
provide this service. Mortality among vasectomy cases is virtually
unknown, and morbidity following vasectomy is also lower than for
female sterilization (ICMR 1982).
Recent data from Tamil Nadu indicate that death rates associ
ated with female sterilization in the public sector are considerably
lower there than in Uttar Pradesh (ranging from 1.0 to 1.8 per 10,000
sterilizations between 1989 and 1994), but still higher than reported
for sterilizations conducted in private nursing facilities or by non
governmental organizations (Ramasundaram 1995). Research in
Karnataka suggests that self-reported symptoms of gynecologic ,iI
problems are significantly higher among women who have undei
gone a tubal ligation than among those using reversible methods ol
contraception or no method (Bhatia and Cleland 1995). Although there
is still debate about causal mechanisms, these data suggest that ad
verse reactions to sterilization when it is performed under low stan
dards of hygiene are not unique toUttar Pradesh, but widespread.
Although sterilization is promoted as a permanent melho I
method failure is also a significant problem. In the ICMR study (ICMI:
1982), method failure ranged from 1.1 per 1,000 for laparotomy to h.'1
per 1,000 for laparoscopy. Rates can be expected to vary according to
the competence of the surgeon and the readiness of the camp to pro
vide the support required for quality service. Such readiness should
include, at a minimum, sufficient light, adequate surgical supplies
(e.g., sutures, thread, needles), and equipment (e.g., autoclaves and
laparoscopes) in working order.
In general, the data from the participant-observation study <d
the three sterilization ramns in I Itlar Pr^rloeh /r„„H 1QQC\ ............. i
322
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Quality of Care in the Sterilization Camps of Uttar Pradesh
major differences in readiness by type of facility (Table 15.3). The camp
held at the PPC appeared to have adequate space, light, and water,
as well as appropriate equipment and supplies (e.g., gloves and slip
pers). The CHC had a somewhat less adequate setting (no running
water) but, like the PPC, it did have a considerable infrastructure and
trained assistants for laparoscopic ligation. In contrast, the PHC had
an operation theater (OT) in poor condition, inadequate lighting due
to irregular electrical supply, and equipment in poor condition, in
cluding evidence of rust.
Although water should be available in every camp setting, of
the three sites visited, only the PPC had running water. Trained as
sistants were available at the CHC and the PPC, but the assistants at
the PHC camp were not actually trained for laparoscopic ligation and
needed constant instruction on procedures from the surgeon. The con
dition of toilet facilities was a problem in all three camps. The Minis
try of Health and Family Welfare has promulgated recommendations
for the proper maintenance of toilet facilities at the camps, but those
recommendations were not being heeded. Ramachandar and Barge
(Chapter 13) and Mavalankar and Sharma (Chapter 14) have observed
a similar lack of consistent hygienic standards at sterilization camps
in Madhya Pradesh and Gujarat, respectively.
Readiness for quality goes beyond a camp's infrastructure and
includes willingness on the part of staff to comply with standards of
care set by the institution. Table 15.4 contrasts the practices observed
in Sitapur District with the standards defined by the Ministry. For
example, at the PPC, the OT is supposed to be fumigated weekly; but
according to interviews with staff, it is fumigated fortnightly. Clients
are asked to arrive early in the day so that clinical and laboratory
tests can be done, but then they must often wait hours for the sur
geon, who may be delayed when several camps are scheduled on the
same day. Camp personnel are supposed to give clients preoperative
instructions, but in practice clients receive little information or reas
surance about what will happen to them before, during, or after the
procedure. They are merely instructed to do what they are told. Prior
to the operation, a woman's pulse and blood pressure (BP) should be
checked, a pelvic examination done, and blood and urine samples
taken and analyzed. In its study of camps in Uttar Pradesh, the ICMR
found that BP was checked in 89 percent of the cases, blood was tested
John W. Townsend • M. E. Khan • R. B. Gupta
323
TABLE 15.3
Infrastructure and equipment, by level of facility:
Three camps in Sitapur District, Uttar Pradesh, 1995
11
i ■
Infra
structure or Condition
equipment recommended
Condition observed, by facility
PHC
CHC
PPC
Fairly adequate
Adequate
■
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Space
Space at least
3mx3m with one
entrance and
one exit
Small,
inadequate,
paint peeling
Lights
Nonreflecting
focus lamps;
working
generator
(required)
Regular
Adequate
power source
inadequate
(power
failure during
observation);
working generator
available
Water
Running water
available and
basin present
No running water; No running water; Running water
basins present
basins present
available
Equipment
BP instrument,
D&C set,
uterine elevator,
scissors,
scalpels,
retractors,
clamps, bowls,
trolleys, stand
and suction
apparatus (all
required)
BP instrument,
D&C set, bowl,
trolleys (in p<)oor
condition);
instruments
water-stained
and rusting
Anesthesia
trolley
Anesthesia trolley Trolley not
or anesthetist
present; instead,
with ether,
oxygen cylinder
endotracheal
plus key
tubes, and
oxygen cylinders
Cleanliness
Clean toilets
with running
water
Toilets present
Dirty toilets,
but without water no water
Gloves
100-200 pairs
of sterile gloves
Present
Present
Present
Staff for
assisting
in ligation
Trained
assistants
Not trained
Trained
Trained
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Adequate
BP instrument,
D&C set, bowl,
trolleys
BP instrument,
D&C set, bowl,
trolleys, suction
apparatus
Respirator bag,
laryngoscope,
and oxygen
cylinders
Boyles apparatus
present
Dirty toilets
BP=blood pressure; CHC=community health center; D&C=dilation and curettage; PHC=primary
health center; PPC=postpartum center.
324
Quality of Care in the Sterilization Camps of Uttar Pradesh
TABLE 15.4
Mandated versus observed operative procedures for sterilization:
Three camps in Sitapur District, Uttar Pradesh, 1995
7!:
Operative procedure
Mandated
Fumigation of OT (PPC)
Weekly
Fortnightly
Instructions to clients
Preoperative instruction
Little information or support
Physical examination and
lab tests
Pulse, blood pressure,
pelvic exam, blood, urine
Completed but irregular
reporting
Sterilization of reusable
needles
20 minutes
5-10 minutes
Time between injection
of anesthetic and
sterilization (CHC)
30-60 minutes
Variable, sometimes hurried
Disinfection of laparoscope
(CHC)
15 minutes
5-8 minutes
Postoperative care
Discharge after 6 hours;
medicines, instructions
Discharge after 3-4 hours;
medicine given, limited
advice
Foliow-up
In 7-30 days
At 2, 4, and 7 days for
dressings and antibiotics
Observed
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CHC=community health center; OT=operation theater; PPC=postpartum center.
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for anemia in 88 percent, and urine tested for diabetes in 95 percent
(ICMR1991). The camps usually performed pelvic examinations, but
it is unclear why 1 in 10 cases did not get all the laboratory tests that
are a prerequisite for this service.
hi the cases observed in Sitapur, all the required examinations
were completed. However, the results of the laboratory tests were
sometimes reported incorrectly. In a review of the registers, we found
that identical levels of hemoglobin were recorded for most of the
women, and one woman whose hemoglobin level was low accord
ing to the test was reported as having an adequate level. Clinic staff
told us that about 70 percent of pregnant women and women with
infants were anemic. One nurse commented that if all the women with
anemia were considered ineligible for sterilization, the camps would have
no clients. Besides, she added, after an ANM spent a great deal of time
motivating women to be sterilized, if the women were then denied the
service, the ANM would no longer be welcome in the community.
As all ANMs from the area are required to attend the camps,
whether they have recruited a case for sterilization or not, the num
ber of health staff at a camp is sizable. During the camps, most ANMs
engage in conversation with one another and have little contact with
ji
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John W. Townsend • M. E. Khan • R. B. Gupta
their clients. In recent years, tents have been set up at larger camps
so that camp personnel can provide information to clients' family
members and other visitors, but the long delay before the surgeon's
arrival is not used for counseling or providing other services. For e\
ample, if a woman accompanying a sterilization client to the camp
would like to have an intrauterine device (IUD) inserted or begin to
use oral contraceptives, those services are not immediately available.
She will be referred to the PHC or given an appointment for a later
date, even though ANMs and medical officers are present. If, how
ever, the camp is held at a PHC or CHC and IUDs are readily avail
able, women wanting to use this method are usually accommodated
right away.
The 1991 study by the ICMR on sterilization camps reports that
97 percent of women opting for sterilization completed the required
consent forms, in return for which they received an incentive pay
ment of Rsl45. In 72 percent of the cases, the client's privacy was re
spected during the preoperative examination, but only 11 percent of
the clients were given a change in clothing for the operation. Only 87
percent of the cases were provided with premedication, and 94 per
cent were provided with local anesthesia. T he laparoscope was prop
erly sterilized in only 73 percent of the cases, and in 9 percent of the
cases it was not sterilized at all.
The support services observed in 1995 were also deficient in qtial
ity, as evidenced by improperly sterilized equipment and discomfort
reported by clients. The Ministry's standard requires reusable needles
to be sterilized in an autoclave for 20 minutes. In practice, needles
were usually left in the autoclave for only 5-10 minutes (Table 15.4).
Injections of anesthetics are supposed to be given 30-60 minutes prior
to surgery. In practice, because the arrival time of the surgeon was
uncertain, the injections were given either too soon or, in some cases,
in a hurried fashion just prior to the sterilization procedure, with the
result that many clients experienced pain.
In our view and that of the staff we interviewed, the surgeons
are generally competent to perform the sterilization procedure. The
weakest component of care is the support provided by the health sys
tem. Camp surgeons complain bitterly about the problems of sup
port, aware that equipment is often not sterilized according to pre
scribed standards and that tests are sometimes not completed. At
326
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Quality of Care in the Sterilization Camps of Uttar Pradesh
times they feel overwhelmed by the system, which is driven by ac
ceptor targets. If a surgeon complains to his superiors, he can expect
little help in resolving the immediate problems and is identified as
an uncooperative member of the team. As the person with ultimate
responsibility for the quality of care in the camp, the surgeon is in a
difficult position.
Postoperative care is an important link between the camp serv
ice and follow-up care within the community. The Ministry recom
mends that patients be discharged after six hours of rest, and that
they be given such medicines as analgesics before departing from the
camps. Patients are to be instructed about the proper care of the
wound, and the local PHC is to provide follow-up from 7 to 30 days
after the operation. In practice, patients are often discharged only three
to four hours after the operation. ANMs feel responsible for the rela
tives who accompany the patients, often providing them with food
and transport. The families also desire early discharge so that they
can reach their villages during daylight hours. The Revenue Depart
ment often provides transportation home for patients. Government
ambulances are available in only a few sites and are not generally
used for patient transport. In addition, many ambulances are not
suited for rural roads.
Patients receive little advice at the camps, although ANMs pro
vide consistent follow-up care in the community. A verification study
of sterilization acceptors indicated that 80 percent received follow-up
services at home (Sawhney 1986). According to recent in-depth inter
views, ANMs make home visits to women who have undergone ster
ilization at intervals of two, four, and seven days after the procedure,
to change dressings and provide antibiotics if they find evidence of
infection. Sometimes the ANM pays for the antibiotics herself to en
sure a client's satisfaction because an unsatisfied client makes recruit
ment of subsequent sterilization cases more difficult. ANMs report
spending about Rs300 on each case to provide tea to family members
during the long day at the camp and to purchase medicines for the client
The ICMR found that only about 11 percent of sterilized women
in Uttar Pradesh were afforded a postoperative recovery period of
more than six hours (ICMR 1991). Ninety-five percent of the cases
received the minimum postoperative advice about care of the wound
and follow-up, and 97 percent received medicines. A trolley or
i
John W. Townsend • M. E. Khan • R. B. Gupta
I ■■
327
stretcher was used to transport the clients to the postoperative care
room in only 73 percent of cases. In other cases, the women were car
ried by a camp assistant or were asked to walk.
!
Issues of Methodology
I <
'A'.
Despite the apparent clarity of these results, several methodological
issues may affect the conclusions arising from this analysis. The is
sue of standards is perhaps the most important one. The fact that the
Ministry of Health and Family Welfare has developed and published
standards of care at the central level does not necessarily mean that
those standards are known to district-level staff. For most staff, they
were neither a part of their preservice nor in-service training, and it
is unclear whether the standards would even be acceptable to front
line providers. At the point of care delivery, all standards are local.
01X6 cannot expect care to be uniform in all settings, and certainly th-ic
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r................
pects between PPCs and PHCs.
The fact that we observed only three camps in this study is n<»l
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problematic from a methodological perspective. The presence of serv
ice-delivery problems in those sites indicates the need for action, al
I ■ ■
though it in no way implies that similar conditions are present in other
districts. It does suggest, however, that an effort should be made to
5' ^5
determine whether similar problems exist elsewhere. Similar studies
in Bihar (Parveen 1995), Gujarat (see Chapter 14 ), and Madhya
p
Pradesh (see Chapter 13) indicate that an unsatisfactory level of services at such camps is widespread. Anecdotal evidence from numer
ous camps also suggests that staff and clients alike would welcome
r
more attention to quality.
Another common issue is the reliability of the observer in complex and often crowded camp settings, which can be reduced to two
. |
questions: Would a different observer witness the same events durfe
r
ing the same session, and would the same observer see the same prob
■3
lems over time in the absence of intervention? In the present case, the
: observer was a physician who had provided services in similar sites.
HtgW-.rx_______ U ______ .1 . .1
. r
One would expect that the measurement of some routines, such as
■fl!
the sterilization of instruments, would be more reliable than obserg I vations about, for example, the arrival time of the surgeon.
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328
Quality of Care in the Sterilization Camps of Uttar Pradesh
Of equal concern is the issue of validity. The physician-observer
was accustomed to the problems of lack of running water, less than
ideal conditions in the OT, and the disorganization of sterilization
camps. Because of this, he may have been less critical of the inad
equacies observed than another observer might have been. Additional
methodological studies are required to better define the parameters
for data collection on the quality of services, particularly indicators
and the use of observations.
John W. Townsend • M. E. Khan • R. B. Gupta
I B;
--;
- >
Conclusions
What does quality have to do with the number of sterilizations and
the achievement of targets? Program managers interpret quality of
care in different ways, depending upon the outcome they desire.
Those managers who are concerned primarily about limiting popu
lation growth tend to associate it with motivating clients to accept a
particular contraceptive—usually a permanent or long-acting
method—rather than offering a range of methods; and they often limit
follow-up to managing complications, rather than providing infor
mation to acceptors about care or support for method switching. Such
managers often regard quality as a feature of the ''contraceptive hard
ware" or of the age or parity characteristics of the acceptor, rather
than as an essential element of the service provided.
The data we have presented indicate that the quality of care is a
multifaceted phenomenon. Readiness to provide quality services var
ies by level of facility. Basic infrastructure (electricity, water, and sani
tation) is lacking in most PHCs and even in some CHCs. Although
the technical competence of the surgeon may be good or even excel
lent, the support systems that would allow the surgeon to provide a
high quality of service are often lacking. Support deficiencies include
untrained assistants at the PHCs, improper procedures used by even
trained staff to sterilize equipment, incomplete coverage during pre
operative screening tests, and inadequate follow-up for controlling
infection and treating complications.
The issue of standards is an important one for program managers
and staff alike. Standards define what is expected of service providers.
If they are consistently not met, the health system has several options:
it can change the standards, withdraw the facility's authorization to
provide the service (as has happened in the case of medical termina-
■■-=1
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tions of pregnancy), or replace the workers. More commonly, program
managers make adjustments in training, supervision, operating bud
gets, and inventory to ensure that locally acceptable standards are met.
The size and location of a camp affect the management of quality.
An urban PPC with an established system for patient flow and a func
tioning laboratory is better prepared to deal with the demands of large
case loads than is a PHC, which normally has fewer cases and infre
quent contact with surgical cases. Large camps (those with more than 20
cases) place a major administrative burden on PHC staff and facilities.
The role of the Revenue Department in recruiting cases and sup
porting the operation of camps also remains controversial. Revenue
Department staff are interested in recruiting sterilization cases to meet
targets and all too often have little or no concern for the long-term
welfare of the clients or their families.
Given the large demand for sterilization services, the Indian
government's strategy of relying on camps is likely to continue as
long as local government staff and facilities are unable to provide ster
ilization services without external assistance, and as long as steriliza
tion targets require the recruitment of large numbers of clients at the
end of each fiscal year. Given that reality, policies and practices are
needed that make an increasing commitment to quality. District au
thorities must make a commitment to provide the facilities, equip
ment, trained staff, and procedures necessary to ensure that basic qual
ity is guaranteed to clients seeking sterilization. Given the large
number of sites, external quality-assurance efforts are unlikely to meet
with much success. It is in the long-term interest of both clients and
the health system that quality be a concern at all times, not just after
quantitative goals are achieved. The basic and essential elements of
improved health services in Uttar Pradesh are an awareness of stan
dards, a focus on the system's readiness to provide quality, and proper
financing to ensure that promised care is delivered. At the district
level, research has a role to play in monitoring the quality of care for
program management. It is essential that the health system monitor
services and measure results. Currently the system measures outputs
in terms of the number of users but invests little effort in monitoring
the inputs or the quality of care being provided.
Improved quality is one of the promising goals of India's new
population policy. But changing priorities means changing those pro
cesses that lead to poor quality and the underutilization of health serv
u
330
Quality of Care in the Sterilization Camps of Uttar Pradesh
ices in states like Uttar Pradesh. The large unmet need for limiting
births identified in the National Family Health Survey, particularly
in settings where the health system has traditionally provided mon
etary incentives to clients and providers alike, is evidence that poor
care results in underutilization of family planning services. Over time,
national, state, and local authorities have made efforts to reduce the
obstacles to quality incamps. Nevertheless, experienced observers of
the program in Uttar Pradesh have noted how the obstacles faced by
providers in the early 1970s seem remarkably similar to those con
fronting providers today. If the national program is to meet both its
goals and clients' needs, it must make a renewed commitment to im
proving the quality of the services it provides.
References
Bhatia, J.C. and J. Cleland. 1995. "Self-reported symptoms of gynecological morbidity
and Lheir treatment in South India," Studies in Family Planning 26(4): 203-216.
Government of India (GOI), Ministry of Health and Family Welfare (MOHFW),
Department of Family Welfare. 1991. Standards for Male and Female Steril
ization. Report, Technical Operations Division. New Delhi: MOHFW.
--------- . 1994. Means Management Information and Evaluation System (MIES). Sta
tistical Reports on the Provision of Sterilization Services. New Delhi: Min
istry of Health and Family Welfare.
Gupta, R.B. 1995. "Field notes from participant observation study, Sitapur Dis
trict," unpublished manuscript. The Population Council, Lucknow.
Indian Council of Medical Research (ICMR). 1982. Collaborative Study on Sequelae
of Tubal Sterilization. New Delhi: ICMR.
--------- . 1991. Evaluation of Quality of Family Welfare Services at Primary Health Cen
tre Level: An ICMR Task Force Study. New Delhi: ICMR.
International Institute for Population Sciences [UPS]. 1994. National Family Health
Survey: Uttar Pradesh. Bombay (Mumbai): UPS.
Kumar, Ashok. 1988. "Health and Family Welfare Programme in Uttar Pradesh An
overview," in Performance of Health and Family Welfare Programme in India, eds.
Prasad Khan and Dastidar Gupta. New Delhi: Himalaya Publishing, pp. 122-140.
Parveen, S. 1995. "Quality of care in sterilisation in rural Bihar: A qualitative
approach," paper presented at the National Workshop on Operations Re
search for Improving Quality of Services, sponsored by The Population
Council, Bangalore, 24—26 May.
Ramasundaram, S. 1995. Institution-wise Death Rates per 10,000 Sterilizations in
Tamil Nadu. Madras: Health and Family Welfare Department.
Ravindran, T.K. Sundari. 1995. A Study of User's Perspective on the Diaphragm in
an Urban Setting. New Delhi: Rural Women's Social Education Centre
(RUWSEC) and The Population Council.
Sawhney, Nirmal. 1986. "Verification study of sterilisation acceptors in Uttar
Pradesh," unpublished report. Population Research Centre, Lucknow.
t
Part IV.
Improving
Quality of Care:
A Change in Focus
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16 The Effects of Service Quality
i
on IUD Continuation
Among Women in Rural Gujarat
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daxa Patel, anil Patel, & Ambrish Mehta
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India was the first developing country to adopt the national goal of
reducing its rate of population growth more than four decades ago,
in the early 1950s. Initially the policy focused on both child-spacing
methods—oral contraceptives, condoms, and intrauterine devices
(IUDs)—and limiting methods—male and female sterilization. The
focus gradually shifted largely to sterilization. The 1992-93 National
Family Health Survey revealed a contraceptive prevalence rate for
India as a 1whole of 41 percent among couples of reproductive age
(UPS 1995). Of these, 75 percent had
been sterilized, 5 p,>ercent were
___________________
IUD acceptors, and about 9 percent were using condoms or oralI con
traceptives (pills). Acceptance of IUDs was reported to be three times
greater in urban areas than in rural areas.
Because the prevalence of spacing methods is low, program man
agers have tended to assume that women would not accept IUDs or
other spacing methods. Relatively few efforts have been made either
to understand the reasons for the low acceptance of these temporary
methods or to devise intervention approaches to improve their ac
ceptance and continued use. This chapter describes an intervention
program in which the response to the IUD> was positive among the
target population of rural women.
V
■■■II
-
Background of the Program
Action Research in Community Health (ARCH), a voluntary nongov
ernmental organization, has been working in rural eastern Gujarat
h
334
Effects of Service Quality on IUD Continuation in Rural Gujarat
since 1980 to develop appropriate primary health care programs. Ten
villages with a combined population of about 8,000 are intensively
covered by ARCH's activities, although the catchment area for
ARCH's clinical services encompasses a much wider area. About 70
percent of the population is tribal; the remaining 30 percent includes
Harijans (out-castes), other so-called backward castes, upper castes,
and Muslims. The economy is dominated by dry-land agriculture, al
though irrigation facilities have been expanded in recent years. The
literacy rate is very low. In 1995 about one-third of the women were
illiterate, and another 15 percent had completed their primary edu
cation without significant numerical or reading ability. Modem health
services are virtually nonexistent in the area. The populace relies
heavily on traditional healers and other unqualified local practitioners. Our field data from 1996 indicate that traditional birth attendants
conducted 90 percent of deliveries at home. A government primary
heal 111 center is located about 8 kilometers away, but its focus is on
female sterilization. People are aware that health workers from the cen
ter visit their houses mainly to encourage sterilization, so they do not
turn to those workers for regular health services.
During the first decade of ARCH's work in this area (1980-90)
we intentionally chose to avoid advocating contraceptive services in
the project area, since we believed that doing so would antagonize
the rural population. As women began to trust us, they grew more
willing to discuss their needs during pregnancy, which included in
formation for ending unwanted pregnancies and preventing future
pregnancies, as well as routine care during pregnancy. Nearly 30 per
cent of the pregnant women who came to ARCH for antenatal care in
1994 said that they did not want to be pregnant. It was clear to us that
these women, while reluctant to accept sterilization soon after the birth
of a second or third child, wanted some means of spacing their pregnan
cies. While most people in this area are unaware of, and hence do not
use, condoms or pills to prevent pregnancy, a relatively large number of
women of all socioeconomic classes know about the IUD. Despite their
desire for spacing, most women are reluctant to accept the IUD, and most
of those who do so continue its use for only a short time.
In a major review of research on contraceptive dropouts in 20
countries, Kreager (1977) observed that the determina^s of discontinned use usually studied were a basic set devised for medical purposes but that these were inadequate with reference to social, cul-
Daxa Pate! • Anil Patel • Ambrish Mehta
1 I
335
tural, and psychological factors. He further observed that the interre
lation of medical, cultural, social, and psychological factors leading
JI
to the early discontinuation of oral contraceptives and IUDs was not
■p
clear. The studies he reviewed generally did not attempt to identify
the reasons for discontinuation in terms of those factors. Kreager
stressed the importance of social and cultural factors in determining
P
the acceptance and continued use of IUDs but acknowledged that the
I
extent to which such factors influenced acceptance or could be ma
nipulated to improve continued use was unknown.
in a more recent study of the quality of care and contraceptive
continuation in six countries, Huezo and colleagues (1993) report that
Elfe high levels of counseling tended, paradoxically, to be associated with
S|| H
a higher risk of discontinuation. However, when they examined the
-•|||
content of the counseling, it became clear that it did not address rel
evant social and cultural concerns that shape women's expectations
and apprehensions. Counseling devoid of such sociocultural sensi
tivity may accentuate rather than mollify women's apprehensions
about the side effects about which they are informed.
-WlS
From our intimate and long interaction with the rural popula
tion in the ARCH project area, we know that most rural women do
si!
not know where the IUD is inserted in the body, what it does, or how
it works. Many have told us that they believe it will ascend into their
chests or be lost in the abdomen, that it causes "heat," or that it could
i
r
• t
cause a loss of weight and energy. A common belief is that with an
IUD in place, the woman's partner will become stuck during sexual
fe'
intercourse and will not be able to withdraw without a doctor's intervention. Some women even fear that an IUD insertion could result
8
* in death. We have learned that such apprehensions and misconceptions are prevalent in other parts of rural Gujarat as well. These fears,
| rooted as they are in false notions of anatomy, must be systematically addressed by means of a sensitive health education program.
’ •£
& | The experience of ARCH in developing such a program and the re3
suits of the program in affecting levels of contraceptive continuation
K, : offer insights to other organizations engaged in family planning efforts.
I
.■
if
•i
I
II
j
vfl
■
m rfe"
II
lj8|
K The ARCH Approach
I
t ■
EL:
ARCH
not initially plan to study IUD acceptance and continuation
in the population being served. The studv evolved in resnonqp tn q npr-
. .-(I. vl Service Quality on IUD Continuation in Rural Gujarat
ji
ceived need in the community, hi conducting the study, as in ARCH's
other health programs, we have maintained proper records, followed
standard medical procedures, and undertaken proper follow-up care.
During the initial phase of the ARCH project (1980-86) its focus
was on curative services and children's health. Although women's re
productive health problems were becoming increasingly apparent, we
were reluctant to undertake a family planning initiative because of the
strong antipathy toward the government's family planning program.
ARCH staff began, however, to perceive a need for fertility control among
the women with whom we interacted. As a result, from early 1987 on,
we began offering spacing methods—rhythm, condoms, oral contracep
tives, and IUDs—to those who came to the dispensary seeking contra
ceptive services. By the end of 1990, 56 women of various castes and
economic backgrounds had requested and received IUD insertions. We
call the period 1987-90 Phase 1 of ARCH's family planning program.
An experienced senior doctor (the first author) inserted IUDs.
We followed the usual textbook precautions and clinically screened
women with obvious gynecological infections, used sterilized instru
ments, and followed an aseptic technique of insertion. We also ad
vised clients to report side effects such as excessive bleeding or pain
and to have the IUD removed in three years' time. More upper-caste
women than women from lower castes accepted the IUD, most likely
because they knew more about this method. Initially our understand
ing of women's fears and misconceptions regarding IUDs was poor.
Hesitant and nonvocal, the women rarely revealed their thoughts to
us. Consequently, we offered little education and counseling that ad
dressed women's deeply rooted and legitimate concerns.
In 1989 ARCH conducted a small study to assess women's fam
ily planning needs and their use of various contraceptive methods.
In six project villages, we registered 492 eligible couples, among whom
282 (57 percent) had already undergone sterilization. From the re
maining 210 (43 percent), we randomly selected 44 women from dif
ferent caste groups for open-ended, in-depth interviews. Eighty-eight
percent of those women expressed a desire to space future births. Only
20 percent were familiar with pills, 40 percent knew about condoms,
and 70 percent knew about IUDs. However, a large majority of the
women had deep fears about IUDs. The acj^al acceptance level of
any of the spacing methods was extremely low.
9
In
III
■ I ft--
T
I ft
1
b ■
illI!
S''
'll-''
^3 p -
■'j
r
I’
I■
Daxa Patel • Anil Patel • Ambrish Mehta
During the early years when women came to the ARCH dispen
sary to have an IUD removed, they attributed any physical problems
they were experiencing to the device. For example, one woman who
had a sore throat thought it was due to the IUD, which she believed
had come up into her throat. She was understandably insistent upon
its removal. Another woman who had pain in her abdomen could
not sleep for two nights because a neighbor had told her that her IUD
might have entered her liver. When we examined her and told her
that the IUD was still inside her womb and the thread was visible in
the vagina, the relief on her face was clear, although she still insisted
upon its removal. In numerous cases, no amount of reassurance was
sufficient to change a woman's mind, and so we removed the IUD.
By 1990, intensive informal interaction had begun with our fe
male health workers (FHWs), who belonged to the same community
and had shared the same fears and beliefs before joining ARCH. By
this time, our relationships with the village women had also im
proved. Informal and intimate discussions with these women revealed
their poor understanding of female anatomy, especially the relation
ship between the reproductive and the gastrointestinal systems. They
had no knowledge of the organs composing the reproductive system,
nor did they know it was completely separate from the gastrointesti
nal system. They did not know that the stomach and the uterus were
two different organs or that the uterus was closed from above. We
realized that merely screening for infections and using aseptic tech
niques for insertion, though essential, were insufficient to ensure ac
ceptance. A specific health education program about women's bod
ies was needed.
Accordingly, the project entered its second three-year phase,
which we call Phase 2, in 1991. In January of that year, we initiated a
process of free and informal information exchange through commu
nity group meetings and on an individual basis when women came
to our clinic for antenatal checkups. For the first time, women were
shown, through slides, models, posters, and pictures, that the repro
ductive organs were completely separate from the gastrointestinal
tract in the abdominal cavity. We also developed a simple low-cost
plastic model of the uterus, cervix, vagina, and fallopian tubes for
the purpose of demonstration. All women who came for an IUD in
sertion were first shown the entire process of IUD insertion on this
1L
338
Effects of Service Quality on IUD Continuation in Rural Gujarat
model. Even women who came to the clinic for other reasons were
encouraged by the FHWs to see for themselves the models and pic
tures. The demonstration included the insertion of an IUD in the
model through the cervix and into the uterus, with the IUD's thread
hanging freely in the vagina. This demonstration, which took only a
Cy., minutes, enabled
i iwomen
------- ;to
j see that the u
terus was separate from
tew
uterus
the stomach and that the IUD could not migrate from the uterus into
the chest. They could also see that the IUD would not cause their p(
to become stuck during intercourse. It became apparent to them
that with the help of the thread hanging in the vagina, a doctor or
FHW could easily remove the IUD at any time. All the possible prob
lems associated with IUD insertion—initial discharge, bleeding, and
pain—were explained to women agreeing to accept this method, and
they were encouraged to visit tire dispensary if they experienced any
of those problems so that appropriate measures could be taken.
During Phase 2 (1991-93), a total of 80 women accepted IUDs.
We screened for reproductive tract infections and used aseptic tech
nique of insertion, as we had in Phase 1. For each woman, we used a
sterilized set of instruments and towels. In addition, for Phase 2, a
senior FHW was trained to insert the IUDs (in Phase 1 only a doctor
had inserted them). In both phases tire neighboring government health
center supplied the same brand of IUDs in standard sterilized packs.
ARCH kept records of all complaints, clinical findings, treatment
given in all subsequent visits, and the reasons for IUD removal. We
made follow-up contacts with women who did not return to the dis
pensary on their own, checking whether the IUD was still in place or
had been removed, and determining the reason for removal.
To analyze the rates of IUD continuation and removal among
acceptors of different demographic and socioeconomic characteris
tics, we have used life-table techniques described by Kahn and Sempos
(1989). We calculated separate rates of IUD removal for the two groups
of women who received IUDs in Phase 1 and Phase 2, in two-month
intervals for up to 24 months after the date of insertion (to 1 April
1995). The data for IUD acceptors in Phase 2 who had not completed
24 months of observation by the end of the study period were con
sidered to be "censored," and these cases were withdrawn from the
analysis at the last full two-month interval of observation. There were
no such cases in Phase 1 (1987-90), as all women who had received
, .
.1
.
Ti--
tI I
' i'I
■hi
I
_____ 1
BlfiS'Sv.
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1
-
-
— —
-
LA LV.11,
i
K-'.
I I-
fe’
Ilk■
Bi
I
I F■I■ I
Ill
gjk ■
Hr-st. f'
E-
i
Br
•'Mi j
<4i
I
■•MJ
——— ----------------
Mean age (years)
Fdnratinn
(°Z3
Education (%)
None
Lower primary (1-4 years)
Upper primary (5-7 years)
Secondary (8+ years)
Total
Social group (%)
Upper castes
Scheduled tribes
Scheduled and other low castes
Muslims
Total
Desire for spacing through use of an IUD (%)
Spacing before first child
Spacing between births
Spacing before permanent sterilization
Total
Phase 1
(1987-90)
Phase 2
(1991-93)
23.9
23.4
21
16
27
36
100
25
11
21
43
100
61
13
14
13
100
39
41
14
6
100
4
58
38
100
(56)
0
58
42
100
(80)
Note: Percentages may not add to 100 because of rounding.
IUD=intrauterine device.
IUDs in that initial period had been followed for at least two years
on 1 April 1995. Cases we were unsuccessful in following up (two
cases in Phase 1 and one case in Phase 2) were considered to have
withdrawn from use in the first two-month interval.
;j|
I
Characteristic
Kkk ‘
3
■
339
TABLE 16.1
Selected characteristics of women accepting IUDs
during 1987-90 and 1991-93: Rural Gujarat
(No. of women)
i IkIB■.
1jjl
Daxa Patel • Anil Patel • Ambrish Mehta
Results
Table 16.1 shows that IUD acceptors in the two phases were similar
with regard to age, education, and desire for spacing. Their composi
tion differs significantly, however, with respect to caste. Whereas up
per-caste women were much more common in Phase 1, tribal women
predominated in Phase 2 (41 percent), indicating greater acceptance
among tribals during the second phase.
The percentage of women who complained of discharge (leukorrhea), excessive bleeding during menstruation, or pain during the
first six months after having an IUD inserted was slightly higher
among acceptors in Phase 1 than Phase 2 (36 versus 29 percent), al-
i-k i Ut. id ui
bervice Quality on IUD Continuation in Rural Gujarat
TABLE 16.2
Complaints of discharge, bleeding, or pain among
Phase 1 and 2 IUD acceptors: Rural Gujarat
Complaint and response
Percentage of women who complained of leukorrhea,
bleeding, or pain within six months of IUD insertion
Of those who complained, percentage who
Had IUD removed
Retained IUD
(No. of women)
ill ||;
Daxa Patel • Anil Patel • Ambrish Mehta
TABLE 16.3
Problems reported within six months of IUD insertion among
Phase 1 and 2 IUD acceptors: Rural Gujarat
Phase 1
(1987-90)
36
80
20
(56)
B.b —----------------
Phase 2
(1991-93)
29
22
78
(80)
i?
MEi
Phase 2
(1991-93)
80
88
29
22
22
13
7
7
20
100
(56)
40
20
14
13
10
3
12
100
(80)
Phase 1
(1987-90)
Phase 2
(1991-93)
Leukorrhea and pain
46
Excessive menstruation
Desire for a child
28
Desire for sterilization
8
0
27
19
30
8
1G
0
100
(38)
___________
Dorranfana nf uunmon frvr v*/Knrr)
Percentage of women for whom
information is available
.. ..
Of these women, percentage reporting
No problems
Pelvic inflammatory disease
Excessive menstruation
Vaginitis
fcy
Cervicitis
Paininin abdomen
K
Pain
IUD=intrauterine device.
though the difference is not statistically significant (Table 16.2). How
ever, among women who complained of complications, the percent
age who had their IUDs removed because of these problems was sig
nificantly higher in Phase 1 than in Phase 2 (80 versus 22 percent) A
possible reason is that during Phase 1, in tire absence of appropriate
counseling about female anatomy, acceptors magnified normal diffi
culties of adjusting to an IUD. hr addition, the women in this group
were continually told by other women that the IUD was unsafe.
As Table 16.3 shows, among IUD acceptors for whom informa
tion on method-related problems was available, a somewhat higher
percentage of women in Phase 2 than in Phase 1 reported no prob
lems (40 versus 29 percent). Substantial majorities of those followed
up in both phases (71 percent and 60 percent, respectively), reported
excessive menstrual bleeding, pain in the lower abdomen' or other
problems within the first six months after having an IUD inserted.
All of those complaints were clinically investigated. At the same time,
as was shown in Table 16.2, the percentage of women who retained
their IUD in Phase 2 was significantly higher than in Phase 1.
More women mentioned leukorrhea, pain, and excessive men
struation as reasons for IUD removal in Phase 1 than in Phase 2 (Table
16.4). The lower incidence of such complaints in Phase 2 likely re
flects changes in women's perceptions due to appropriate health edu
cation. The desire to have another child was the most common rea
son for removal given by women in Phase 2. Six women (16 percent)
in Phase 2 also reported spontaneous expulsion of their IUDs, which
may have been related to the fact that four of those IUDs were in
serted by a senior FHW who was under training.
Phase 1
(1987-90)
No information available (% of women)
B " Total (%)
(No. of women)
IUD=intrauterine device.
>■
TABLE 16.4
Reasons for IUD removal among Phase 1 and 2
IUD acceptors: Rural Gujarat
*. zaKg■.
h'
---------------------------------------------------------------------Reasons for IUD removal
Spontaneous expulsion
Other
3
jI
Total
(No. of women)
I
IUD=intrauterine device.
15
3
100
(39)
■
J
■
Figure 16.1 shows curves of IUD continuation rates in the two
phases, based on life-table analysis as described earlier. Six months
after insertion, 89 percent of the women in Phase 2, versus 66 percent
in Phase 1, continued to have their IUDs in place. The corresponding
figures at the end of one year were 77 percent and 48 percent, and at
two years, 52 percent and 28 percent. These differences are highly
significant (p = .001). The rate of IUD continuation for all intervals
was also significantly higher in Phase 2 (p < .01). We obtained this
difference by considering removal of IUDs for all reasons as drop-
?
342
Effects of Service Quality on IUD Continuation in Rural GtffArat
Daxa Patel • Anil Patel • Ambrish Mehta
I.
100
100
«’
90’bi
Q
80-
ot
70-
a
Phase 2 (1991-93)
90-
g 80-
Phase 2 (1991-93)
■e-
o
22
24
70-
w
.E 60-
8 50-
c 60 -
33
8 50-
a>
uj
(Q
40-
®
o
30-
®
o
Q.
20-
i 20-
Phase 1 (1987-1990)
F
I
li
0-I---------- T----------- T------------ T------------- 1---------------I-------- T-------------T----------- T---------------- T--------- T------------ 1------------1
0
2
4
6
8
10
12
14
Phase 1 (1987-1990)
e
g) 40 S
10-
16
18
20
22
24
Time since IUD insertion (months)
FIGURE 16.1 IUD continuation rates in Phases 1 and 2, taking into
consideration removals for all reasons: Rural Gujarat
outs. The difference between the two phases increases further when
we consider only the removals due to IUD-related problems such as
leukorrhea, pain, and excessive bleeding (i.e., excluding removals due
to the desire for more children or to switch to sterilization).
Figure 16.2 plots IUD continuation rates in the two phases, tak
ing into consideration only removals due to IUD-related problems.
Here, as in Figure 16.1, the differences in continuation rates at all in
tervals are highly significant (p = .0002).
Bi
-fl Br-iS
i
fc
If
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II .’
h
JI <
s ■>
-3'I
Discussion
ir
3 13
This study does not demonstrate that the IUD is either the most ap
propriate or the most preferred spacing method available for rural
women. What it does indicate is that when women are given a choice
of methods, IUD continuation rates can be improved markedly by
providing health education that effectively addresses women's ap
prehensions and concerns about the method. Although the study may
have overlooked other differences between the two intervention
phases, we do not believe that the marked decline in the rate of IUD
discontinuation during Phase 2 was the result of any other factors
operating in the project communities. Living conditions and ameni-
■i
ri ■
1
|
•
TK'
f
“v.
1
30-
100-0
2
4
i
i
ir—
ir—i ------------ 1-------------- r-
6
8
10
12
14
16
18
20
Time since IUD insertion (months)
FIGURE 16.2 IUD continuation rates in Phases 1 and 2, taking into
consideration removals due only to IUD-related problems: Rural Gujarat
ties available to the communities remained essentially unchanged over
the two study phases. One difference between the two periods was
the significantly higher proportion of tribal women among IUD ac
ceptors in Phase 2. It is unclear, however, whether this difference
would have contributed to a widening or narrowing of rates of IUD
continuation between the two study periods. In any event, the key
point is that anxiety and apprehension about the IUD prevent poor
women from accepting the method in the first place. Once these fears
are allayed, women are probably more willing to tolerate the discom
fort of an IUD than to risk another unwanted pregnancy.
The proportion of women who reported leukorrhea, bleeding,
or pain during the first six months or even later after accepting an
IUD was essentially the same in both phases. However, the rate of
IUD removal due to those problems was significantly lower in Phase
2. This finding strongly supports our contention that dissemination
of specific, easily understandable information addressing women's
deeply held beliefs and fears about the female reproductive system
can have a positive effect on the continuation rate of IUDs.
Discussions with our FHWs revealed how the information network within the community was gradually established. They indicated that in Phase 1 their own understanding about the IUD was
. V lit Quality on iUL> Continuation in Rural Gujarat
much poorer than in Phase 2. During Phase 2, they worked in the
clinic as well as in the community and undertook other activities re
lated to women's health, including antenatal and postnatal care and
health education. They were thus better able to win the trust of the
community in Phase 2. If women accepting an IUD during Phase 1
had any sort of health problem afterward, they attributed it to the
IUD. They were encouraged to do so by family members and neigh
bors, who repeated negative rumors about the IUD and advised them
to have it removed if it caused even minor discomfort. During Phase
2, however, IUD acceptors regularly discussed their health problems
with the FHWs and were usually reassured. The fieldworkers, for
example, explained that the reproductive system was unconnected
to the gastrointestinal system—comparing it to "a box closed from
above." Because of the project's efforts to provide health education
during Phase 2, the understanding of the community as a whole
increased.
The data obtained in this clinical setting, although based on a
small sample, suggest that our approach has promise and needs to
be followed up in a wider community setting. During both phases of
the study, we were unable to carry out bacteriological tests on women
with specific complaints. We found no evidence of gynecological in
fection during clinical examinations preceding IUD insertions (al
though one woman in Phase 2 was subsequently detected through
laboratory tests to have an infection, and her IUD was promptly re
moved). Despite their complaints about the IUD, a large majority of
women who had received appropriate health education could be re
assured and were willing to continue with the method. On follow
up, these women were usually found to have no adverse effects. This
is an important finding at a time when many family planning pro
grams have largely abandoned the IUD.
With respect to the replicability of our intervention strategy, de
veloping a good relationship with the community was necessary to
learn about women's misconceptiions about their bodies, but counseling clients did not require either an exceptionally high order of
dedication on the part of the health staff or intimate and prolonged
interaction with clients. Any preinsertion counseling must, however,
incorporate specific information about female anatomy, using readily
available visual materials. The models we used were simple and in
expensive, and government clinics and staff could easily replicate our
I
|
1
■•W
■W'
Daxa Patel • Anil Patel • Ambrish Mehta
approach. On the basis of our experience, we conclude that the IUD
can be one of a number of contraceptive choices for Indian women.
who, in large numbers but with subdued voices, are demanding meth
ods for spacing births rather than experiencing unwanted pregnandes or undergoing sterilization.
References
.a I'
'3
1
I
I ■
ir
■I I
Huezo, C.M., U. Malhotra, A. Sloggett, and J. Cleland. 1993. "Acceptability and
continuation of use of contraceptive methods: A multi-centre study," in
Proceedings of the XIHth World Congress of Gynaecology and Obstetrics, eds. E.
S. Teoh, S. S. Ratnam, and M. Macnaughton. Vol. 1, pp. 117-135.
International Institute for Population Studies (UPS). 1995. National Family Health
Survey (MCHand Family Planning): India, 1992-93. Bombay (Mumbai): UPS.
Kahn, Harold and Christopher Sempos. 1989. Statistical Methods in Epidemiology.
New York: Oxford University Press.
Kreager, Philip. 1977. Family Planning Dropouts Reconsidered: A Critical Review of
Research and Research Findings. London: International Planned Parenthood
Federation.
Jay Satia • Sangeeta Subramanian Sokhi
17 Developing an
Alternative System of
Monitoring Indicators for
the Family Welfare Programme
347
So far the emphasis of the Family Welfare Programme in the coun
try has been on the target oriented approach with focus on steriliza
tion. Because of the profile of the acceptors, it has not been possible to
achieve the desired demographic goals. Now that with the changing
age structure in the country, more and more young couples are enter
ing the reproductive age group, the focus has to change from perma
nent methods to temporary or spacing methods. (Mishra 1995, p. 7)
II
1
Women's health advocates have documented the program's lack
of responsiveness to women's needs and its treatment of users with
insufficient dignity and respect (Nataraj 1994). Studying quality of
I
care in 16 health facilities in Tamil Nadu, Ravindran (1994) found that
I
basic amenities such as running water were not available in all facilities, that only five had toilet facilities, and that even those five were
condition. The
facilities or
often
did nor
not remain open when
|<’
in poor condition,
ine laciuties
ten oia
wnen they
mey
should have, compromising the availability of services. Although
women clients preferred female to male doctors, five facilities did not
' -S
Ehave female doctors; many clients turned to private lady practition' ___________
ers. In a 1987-89
______
study, the Indian Council of Medical Research also
|
identified shortcomings in the health facilities of 19 states and union
ijr
territories (ICMR 1991).
II
■II
JAY SATIA & SANGEETA subramanian sokhi
For nearly two decades, demographically determined targets have
been the driving force for the Family Welfare Programme in India.
Hie government's goal of reducing fertility and its assumptions about
the public's acceptance of various contraceptive methods determine
its acceptor targets for specific methods. These targets are then allo
cated to the states, largely on the basis of population size but also on
the basis of the states' past performance and family planning infra
structure. In turn, the states allocate targets to their districts, the dis
tricts allocate them to primary health centers (PHCs), and the PHC
medical officers allocate them to their field staff. Although this topdown target system simplifies the monitoring of program and staff
performance, it has led to an overemphasis on sterilization, poor qual
ity of care, and lack of concern for clients' needs. As a result, public
opinion in India favors the abolition of targets (Bose 1988).
Numerous studies (e.g., Satia and Jejeebhoy 1991) have noted
the harmful effects of method-specific targets on family planning,
which include the neglect of maternal and child health (MCH) serv
ices, poor quality of services, and some falsification in reporting. It is
also well known that considerable variability exists in auxiliary nurse
midwife (ANM) competence, work facilities, and logistics support.
The Department of Family Welfare, Ministry of Health and Family
Welfare, has noted the harmful effects of overemphasizing demo
graphic targets:
346
I
The research literature indicates that considerable effort is needed
I
1
to
improve
the quality of reproductive health care in India. In addi
1W
i ■to access to and availability of services, issues to be addressed
1I1:1 tion
include method choice, information provided to clients, technical com
3
Si E
1
I •
1:
'■ 1
>1
J"
■
petence of providers, follow-up care, and mechanisms for continuity
of use. At a recent seminar to review evidence, participants reported
many deficiencies in quality of care, in particular clients' lack of
method choice and limited information given by providers about in
dividual methods. They noted that providers seldom discussed
contraindications or side effects with clients. Access and availability
are better in southern states such as Tamil Nadu and Karnataka than
in northern states such as Uttar Pradesh, but even in South India, fe
male sterilization remains the most emphasized method. Clients of
ten rate the technical competence of private providers as superior to
that of government providers, yet despite these quality problems, a
majority of clients have expressed satisfaction with the services they
received from the Family Welfare Programme, perhaps because they
had low expectations (Foo 1996).
34b
Developing an Alternative System of Monitoring Indicators
India has considerable unmet need for contraceptive services.
According to the 1992-93 National Family Health Survey, 8.5 percent
of married women between the ages of 13 and 49 who wanted no
more children and 11 percent who wanted to space future births were
nevertheless not using contraception. The use of spacing methods re
mains very low, with only 5.5 percent of couples using spacing meth
ods, often for the purpose of limiting their family size. Therefore, only
one-fourth of the need for spacing has been met (UPS 1995, p. 188).
■
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Rethinking the Monitoring Process and Indicators
1
In the new approach, when we are moving away from the target
approach to [a] client approach, an important issue would be to find
a way to judge the performance of the health workers, keeping in
view the new goal of containing family size and good spacing be
tween children in view to improve maternal and neo-natal health.
(GOI, Department of Family Welfare 1995, p. 1)
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Two recent decisions by the Indian government have led to the ne
cessity of rethinking the monitoring processes and indicators in the
Family Welfare Programme. First, in 1995 the government declared
18 districts in selected states as target-free and committed itself to
making the entire program target-free in April 1996. Second, at the
policy level it has proposed a paradigm shift from the vertical ap
proach to family welfare, in which family planning is segregated from
MCH, to an approach integrating reproductive and child health. Both
of these changes require a client-centered, quality-of-care focus. Thus
a change in program indicators will not only affect the implementa
tion of the current Family Welfare Programme, but also provide the
underpinnings for a broader array of reproductive health services.
There have been many discussions and several workshops on
alternative indicators for the program. Two meetings of district health
officers from the target-free districts have also taken place. A work
shop was organized in September 1995 as part of the preparatory pro
cess for a proposed World Bank-assisted Reproductive and Child
Health Project on monitoring and evaluation issues. The meeting high
lighted tlie need for, and identified possible actions to move toward,
a new system of indicators and procedures for monitoring and evalu
ation. These activities have underscored the urgency of introducing
alternative indicators, and they have pointed to the need for concerted
work and continuing dialogue among key stakeholders before a new
system of indicators is introduced. The government's draft concept
expresses this need for dialogue as follows:
Jay Satia • Sangeeta Subramanian Sokhi
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Subsequently the government appointed a task force to develop an
alternative system of indicators.
Targets have long been used as a means to ensure staff account
ability. Because the government has decided to move away from de
mographic targets toward client-centered, high-quality reproductive
and child health services, many field-level managers are concerned
that accountability and performance will decline if targets are re
moved. In a program as large as India's, with more than 150,000 field
staff, implementing such a major change is an enormous challenge. It
requires not just a carefully worked out alternate system of indica
tors and monitoring, but also a reorientation of field staff and a fun
damental shift in operational methods.
The experience of target-free districts varies considerably. Our
visits to several suggest a mixed response. The announced removal
of targets produced varied initial reactions ranging from relief ("I do
not have to worry about cases anymore?") to disbelief ("This cannot
be true!" "They will impose targets again!") and confusion ("How
do we know that workers are working?" "What is expected of me?").
In one district, although targets were no longer prescribed for con
traceptive methods, information on the number of acceptors contin
ued to be collected. Because the program there made no effort to in
troduce a major change in workers' emphasis, there was no
perceptible change in the acceptance pattern. In that district, the offi
cials thought that it was not desirable to shift to the target-free ap
proach but preferred to include some quality indicators in the cur
rent monitoring system. Perceptions of indicators of quality varied.
Some officials thought that when evaluating worker performance,
cases of younger acceptors and couples with two or fewer children
who accepted a permanent contraceptive method should be given
greater weight than other cases, to reflect the higher demographic im
pact. Clearly, more effort will be required to create a common vision.
1
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Case Studies of Alternative Indicators
The shift to a target-free approach has prompted considerable experi
mentation. Several managers within the government and nongovern-
350
Developing an Alternative System of Monitoring Indicators
mental organizations (NGOs), with or without assistance from other
agencies, have begun to experiment with alternative indicators and
with management systems to support the use of those indicators. Be
low we describe five examples of such experimentation. Most of these
experiments were still at an early stage of implementation at the time
this chapter was written, and documentation is needed to continue
to learn from their experiences.
Jay Satia • Sangeeta Subramanian Sokhi
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Ahtnednagar District, Maharashtra
An operations research project is underway in Ahmednagar District,
implemented jointly by the Directorate of Health Services of
Maharashtra and the Foundation for Research in Health Systems
(Murthy and Barua 1996). A baseline survey was carried out to ascer
tain the situation regarding MCH, family planning, and quality of
care in other reproductive health services. It revealed a number of
weaknesses in the district's health system.
To provide comprehensive MCH and family planning services
through the village-level primary health care system, the project of
fers services through a multipurpose camp held in each village with
more than 1,000 inhabitants that does not have a health center. Immu
nization, antenatal care, and family planning services are all offered in
these camp settings, and a schedule and routine for the camps has been
worked out. Lady health visitors and ANMs provide antenatal care
and family planning services; ANMs also perform vaccinations. Male
multipurpose workers weigh children. Medical officers examine highrisk cases. All staff are involved in providing health education. In four
out of five villages where space was not available to ensure clients'
privacy, the community has made suitable space available.
Tire emphasis in the project has been on increasing the coverage
of all services, and coverage has risen to nearly universal levels in
the project area. To ensure full coverage, the project has introduced a
family health card to record all services provided to family members.
The family health card has replaced the numerous registers that
ANMs had to maintain. It consolidates records of immunization, preg
nancy history, disease surveillance, family planning follow-up, ante
natal care, delivery, and postnatal services. Although the project's
experience with this record-keeping procedure is still limited, it is
seen as a major step toward streamlining the work of ANMs.
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In the next phase the project proposes to incorporate an essen
tial reproductive health package that includes screening and treat
ment for reproductive tract infections (RTIs) and sexually transmit
ted diseases (STDs); abortion services; family planning information,
education, and communication (IEC); and counseling. The experience
of the project thus far indicates that strengthening existing services
creates a strong foundation for including a broader range of services
at a later stage.
Pregnancy-Based Approach in
Agra and Sitapur, Uttar Pradesh
The Population Council has been implementing an operations re
search program in three blocks of Agra District and five blocks of
Sitapur District since August 1995 (personal discussions with Dr. M.E.
Khan and Dr. Saumya RamaRao of the Population Council). In this
pregnancy-based approach, ANMs are asked to visit each pregnant
woman three times before delivery and three times afterward. ANMs
are encouraged to discuss family planning during the postnatal vis
its. The indicators used by this project emphasize antenatal and post
natal care coverage, use of spacing and permanent contraceptive
methods, and IEC activities.
The management information system used to support these
monitoring indicators is based on the 42-column register developed
for the Child Survival and Safe Motherhood Programme and on the
eligible couples register, with the addition of two columns to assess
unmet need (clients' desire to limit and to space births). The empha
sis is on ensuring continuity of care beginning with pregnancy. The
coverage indicators include services for pregnant women, use of per
manent and spacing contraceptive methods, and community cover
age with orientation training camps.
This approach involves changes in the philosophy of the service
program to meet clients' needs, in the work routine of ANMs, and in
the purpose of monthly meetings for in-service training. Many addi
tional changes are needed, including greater involvement of male
workers and the introduction of training camps devoted to reproduc
tive health and gender issues. As the project has been in existence for
only a short time, it is too early to evaluate its performance. Initial
reports, however, indicate that the team spirit, self-esteem, and con-
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Jay Satja • Smgeeta suui -
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fidence of ANMs have improved. Assistance from supervisors to
ANMs has also contributed to the effectiveness of this system.
Vikalp Strategy in
Tonk and Dausa Districts, Rajasthan
Vikalp (meaning "Alternative") is a framework developed by the In
dian Institute of Health Management Research, Jaipur, and imple
mented by the Rajasthan government since March 1995 (Vikalp 1996).
It is a district-based approach, and client segmentation is the basis for its
planning and implementation strategy. The focus is on assessing unmet
need for family planning—especially for spacing—on the basis of
women's responses to questions about whether they want another child,
and if so, how soon. Key elements of the Vikalp strategy have included:
• holding women's health camps once a month in the PHC to ad
dress women's health issues and to promote the use of spacing
methods such as intrauterine devices and oral contraceptives;
• involving traditional medical practitioners and local NGOs in
the Family Welfare Programme by providing them informa
tion on spacing methods and encouraging them to be depot
holders for contraceptives;
• identifying and training traditional birth attendants to provide
safe delivery and better postpartum care; and
• involving members of village councils, especially female mem
bers, in community education and in organizing the health camps.
The project has used a camp approach to deal with other gyne
cological needs of women. According to program managers, this ap
proach has elicited a positive response from the women. The manag
ers now propose to strengthen the static service-delivery point at the
block level by converting it into a comprehensive reproductive health
center that will operate as the nodal point for service delivery. Man
agers also plan to systematize referrals from the field to the repro
ductive health center, and to follow up clients treated at the center
when they return to the field.
*
A combined distribution and training project in Bundi District has
been supported by the United Nations Population Fund (UNFPA) in
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essentially two components: (1) extension of the Community-Based
Distribution of Contraceptives (Jan Manual) Project, which began in
Udaipur District; and (2) training of ANMs tor the prevention and
management of RTls, including routine testing of pregnant women
for syphilis as part of the antenatal care package.
In this district the project focuses on MCH services and empha
sizes MCH coverage indicators. Of particular interest is the use of
indicators of continuation rates rather than of the number of users of
spacing methods. Certain changes have been made in the manage
ment information system for this project. ANMs' monthly reports now
have information on the number of new acceptors for each method,
the number of continuing users, and the number of acceptors who
have discontinued use. During monthly meetings the PHC medical
officers are encouraged to probe ANMs for details on method switch
ing, and for clients' reasons for discontinuing contraceptive use. The
emphasis is on improving continuation rates rather than on enroll
ing ever-larger numbers of new acceptors.
Each ANM maintains a register for RTI cases indicating the dates
of the first visit and follow-up visits. Every month she reports on the
number of first visits and the treatment given, follow-up visits, oul
come of treatment, and details of referral, if any. Some of the treat
ment protocols for RTI management had to be modified because pre
ferred drugs were not available or were too costly. A more serious
drawback is that the project has not had much success in partner re
ferral and treatment, and it has not yet defined a successful strategy
for addressing this problem. Impact assessment had not been under
taken at the time of this writing, as the project was still in its early stages.
Tamil Nadu's Experience and Indicators from
the Rural Women's Social Education Centre
In Tamil Nadu, program managers agreed that method-specific tar
gets should be removed. They implemented an alternative approach
in two phases (personal discussions with S. Ramasundaram, Special
Secretary of Health and Family Welfare, Government of Tamil Nadu).
During the first phase (1994-95), targets for nonhealth staff were re
moved. During the second phase (1995-96), the top-down target sys
tem was replaced and ANMs were asked to determine their own
354
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Developing an Alternative System of Monitoring Indicators
workload targets. Those targets were to include delivery of MCH serv
ices and referrals by ANMs of cases requiring treatment for RTIs or
STDs. ANM workloads for family planning depend upon the number
of couples with two or more children who accept a permanent method
during the year and upon the percentage of couples with two or fewer
children who continue to use spacing methods over the same period.
A systematic process was developed to implement these reforms.
It was first discussed at a meeting called by the ANMs' Association.
Addressing the genuine grievances of ANMs began the process of
empowering ANMs and creating individual accountability. The Ru
ral Women's Social Education Centre (RUWSEC), an NGO in
Chengalpattu District, Tamil Nadu, acknowledged that change must
start at the grassroots level and that ANMs held the key to making
the system more client-focused.1 No significant change took place in
the state's management information system, however. There is still a
need to involve male workers in the new process, and not all PHC
medical officers share the vision of empowering ANMs.
The indicators used by RUWSEC cover all the organization's
services and their outcomes for pregnancy, birth, and postpartum care;
abortion and contraception; RTIs and STDs; and adolescent rep J
ductive health. A list of illustrative indicators includes the following:
• the percentage of women using a safe-delivery kit for home
delivery;
• the number of women developing postabortion complications
or infections;
the percentage of women practicing contraception;
• the percentage of men practicing contraception or using
condoms for noncontraceptive purposes;
• the proportion of women whose last two deliveries occurred
at least two years apart;
• the percentage of women and men seeking medical help for
RTIs and STDs;
the percentage of help-seekers whose spouses could also be
contacted and treated;
• the proportion of adolescent boys and girls who know:
- how conception takes place
- about various methods of contraception, including natu
ral family planning methods such as periodic abstinence
and withdrawal
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355
- how STDs, including the human immunodeficiency virus
(HIV) and acquired immunodeficiency syndrome (AIDS),
are transmitted, and how to practice safe sex
- about basic preventive and promotive health practices; an< I
• the proportion of adolescent boys and girls seeking counsel
ing and treatment for reproductive and sexual health concerns
Lessons
What lessons can be derived from these early experiences? First, it is
necessary to replace acceptor targets with another driving force for
the program, which we call an alternative strategic driver. Most of
the experiments discussed above have emphasized the provision of
various services. Some focus on unmet need for contraception. They
regard this as a first step, which can be followed up by expanding
the range of reproductive health services and improving their qual
ity. Second, almost all interventions are attempting to alter the rela
tive emphasis placed on the services provided. Most of them suggest
an increased focus on MCH, particularly antenatal care, largely
through female outreach workers. The involvement of male workri
and medical officers still needs to be addressed in most ol these e\
periences. Third, many management systems will need to be changed
if the focus is to shift to client-centered, high-quality reproductive and
child health services. These changes include how work is organized,
how meetings are held and what the meetings emphasize, how su
pervision is carried out, what type of management information sys
tem is used, and how a district supports staff at the field level. In the
projects we have described, such changes were being implemented in
crementally. Moreover, while considering changes in indicator systems,
it is necessary to consider other attendant changes that also will be
required. Finally, districts and PHCs will need considerable technic.il
support in making the transition to an alternative system of indicators.
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A Framework for Developing an
Alternative System of Indicators
Now that targets will no longer be the driving force of the Family
Welfare Programme, a major issue is what alternative strategic
driver—or drivers—should be used. Other issues to be addressed arc
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System of Monitoring Indicators
Jay Satia • Sangeeta Subramaman Sokm
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the program s relative emphasis on various aspects of its operations,
the appropriate mix of indicators and sources, the criteria for select
ing indicators, and how the alternative system of indicators is to be
assessed.
Altemative Strategic Drivers
Several possibilities need to be considered for alternative strategic
drivers. These include increasing health care coverage, meeting unmet
need for contraception, ensuring a high quality of care, and decen
tralizing planning as an implementation vehicle.
Increasing coverage. Increasing coverage involves substituting new
program service indicators in place of targets. For example, in
Bangladesh, when the government decided to de-emphasize method
specific targets, program focus shifted to contraceptive prevalence,
which has become the accepted way to measure performance. Tar
geted coverage levels may vary for different population segments.
Many Iridian states have revised, or are considering revising, their
management information systems to reflect this new focus. In
Maharashtra, for instance, the focus is now on coverage within a
subcenter area by a variety of services rather than on services pro
vided by a specific ANM. The main instrument for organizing work
becomes the family register or card. The record of services it provides
can emanate from specific service-delivery sites (immunization ses
sions, camps, clinics, etc.) or from service-delivery records. The cov
erage-based focus comes closest to the current target system. Its ad
vantage is that it removes method-specific targets from family
planning activities and minimizes conflict among providers for
credit for services. While this focus leads to improved accessibility
and availability of services, it does not directly encourage or result in
improved quality of care.
Reducing unmet need. Reducing unmet need entails replacing tar
gets with indicators of the unmet need for services. Indonesia, for
example, has replaced method-specific targets with what are called
demand fulfillment" targets. For family planning, this means plac
ing the focus on couples who do not desire more children or who
wish to space their next child but are not practicing contraception. 2
For most other MCH and reproductive health services, such as ante
natal care, the goal remains to provide services to all who need them.
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The advantage of using unmet need as a focus is that it separate:? the
responsibility for providing services from that of institutionalizing
small-family norms. It may also lead to a focus on those geographic
areas where unmet need may be greatest and appropriately empha
size demand creation and service-delivery interventions.
Ensuring quality of care. The major driving force behind ensuring
quality of care is making high-quality services—defined according to
specific standards—accessible and available.3 Because accessible serv
ices of high quality tend to be better utilized than other services, cov
erage can be expected to increase over time, and unmet need to de
cline. This may not happen, however, in the case of services whose
need is not perceived by prospective clients. For instance, many women
have silently suffered from RTIs rather than seeking medical attention
for their problems. Therefore IEC may have to accompany improved
service quality if the use of such services is to increase rapidly.
Decentralizing plans as an implementation vehicle. The existing sys
tem of targets has been implemented largely from the top down, each
higher level allocating the targets to the next lower level. Perhaps the
most fundamental change in a move toward a client-centered, qua I
jty approach must be increased decentralization, which is g(‘ner.illv
regarded as a prerequisite for any such change (Satia, Mavalankar,
and Sharma 1994). The Indian government has recently recommended
the involvement of grassroots workers in decisionmaking:
. . . grassroots workers may get together to give an estimate of likely
acceptance of various family welfare activities in 1996-97 for every
quarter in their area of jurisdiction to form part of their Pl IC level
Family Welfare and Health Care (FWHC) plan for 1996-97. The
FWHC plans should also contain materials and supplies required to
accomplish the activities estimated by grassroots level workers as
well as non-governmental agencies, heads of village councils, pri
mary school teachers in the area and population covered by that
PHC. . . . The performance of each PHC would need to be evaluated
against their own plan by the district health and family welfare sys
tem at the end of every quarter to advise them suitably. There would
also be need to tune the 1EC activities in the PHC areas and the dis
tricts to promote this bottom-up approach of planning and implemen
tation of a sensitive programme like family welfare. ... A timetable
for preparation of plans at various levels may be set. (GOI 1996, p. 1)
The plans, generally prepared at the field level, thus become the
strategic driving force for the program. Yet the plans at each succes-
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Developing an Alternative System of Monitoring Indicators
sive higher level are not simply the aggregate of plans made at lower
levels: Each level must also plan its own activities. Thus, while ANMs
at the subcenter level must plan their own activities, the PHC must
plan to provide support through inputs from the medical officers and
supervisors, and for necessary logistics support. The district level may
need to plan for improving the access, availability, and quality of serv
ices. The plans at each level must use an appropriate mix of cover
age, unmet need, and quality-of-care objectives.
In conclusion, one "driver" (objective) may be easier than another
to implement at a particular time, but a single driver may not be the best
for all situations. Therefore, program managers may prefer to change
drivers as conditions change. For instance, areas with low coverage
may focus first on increasing coverage, areas with modest coverage may
focus on reducing unmet need, and areas with reasonable coverage may
focus exclusively on improving the quality of care. A locally developed
plan may be able to incorporate a suitable mix of these objectives.
Jay Satia • Sangeeta Subramanian Sokhi
359
TABLE17.1
Needed changes in relative emphasis:
Monitoring indicators for the Family Welfare Programme
J
Reduced emphasis on
Increased emphasis on
Output/outcome (such as the number of
acceptors of various contraceptive methods)
Ensuring that high-quality services are
provided
Monitoring staff
Enabling and motivating staff
Corrective action when things go wrong
Planning for high-quality services
Services provided by staff
Client reach and coverage
ties) that result in desired outputs and outcomes. This requires a ju
dicious mix of data sources: routine reports, supervisors' reports, sur
veillance areas, rapid assessment, and special surveys, including con
current evaluation. Thus, moving to an alternative system of indicators
requires developing a corresponding system of data collection and
analysis. For instance, workers may report on inputs and coverage,
supervisors may carry out quality audits, and special surveys can be
used to measure outcome indicators.
Changes in Relative Emphasis
If the Family Welfare Programme is to move toward a client-centered,
quality focus, the relative emphasis on various aspects of its opera
tions also needs to change, as indicated in Table 17.1. Managers need
to plan for and review quality regularly, enable and motivate staff to
deliver high-quality services, and focus on all the service providers
in the community.
Whether an indicator should be included in the alternative system
should then be decided on the basis of whether it will sufficiently alter
the emphasis in the desired direction. Measuring how managers spend
their time on various tasks is a simple way to judge the relative empha
sis. For example, how much time do managers spend monitoring staff
performance as compared to listening to and addressing the grievances
of staff? The answer may determine the relative emphasis placed on
monitoring versus enabling and motivating staff.
Mix of Input, Process, Output, and
Outcome Indicators and Sources
Any alternative system needs to use a combination of indicators re
flecting the availability of necessary inputs and the process (of activi-
Criteria for Selecting Indicators
It is important to pay adequate attention to the indicators that are to
be used for monitoring a reproductive health program. A good indi
cator has a number of desirable attributes (Graham and MacFarlane
1996; WHO 1994). Specifically, it should be:
• valid—actually measuring the phenomenon it is intended to
measure;
• reliable—producing the same results when used to measure
the same phenomenon more than once;
• specific—measuring only the phenomenon it is intended to
measure;
• sensitive—reflecting changes in the state of the phenomenon
under study;
• useful—indicating follow-up action that is immediately apparent;
• accessible—ensuring results are readily available in a usable
format at appropriate time intervals;
• understandable—making certain that results are easy to define and to interpret; and
• representative—adequately encompassing all the issues or
population groups it is expected to cover.
developing an Alternative System of Monitoring Indicators
Ideally, the indicators should be useful, not just for monitoring and
evaluation, but also for planning, especially at the local level. Thus
the set of indicators needs to include a subset that can be used by
grassroots health functionaries such as ANMs to plan their activities.
4
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Jay Satia • Sangeeta Subramanian Sokhi
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The sources of data for these indicators are generally worker or
supervisor reports.
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Framework Elements
To assess an alternative system of indicators, we need to ask the fol
lowing questions about it:
• Is it derived from an appropriate mix of "strategic drivers"?
• Will it result in a desired shift in emphasis in program operations?
• What mix of data sources is needed and how will they be used?
• Does each indicator meet the desired criteria?
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Illustrative List of Indicators
The illustrative list of indicators that follows is derived from various
sources. The development of indicators should be in consonance with
the development of reproductive and child health services
Access and Availability Indicators
Access and availability indicators help to answer the question: Are the
services available? They indicate whether desired inputs are in place
and whether activities to make these services available are taking place.
An illustrative list of input indicators includes the following:
• percentage of ANMs with equipment for testing blood pressure• percentage ANMs trained in RTI detection and referral; and '
•percentage of PHCs providing medical termination of pregnancy.
The data source for these indicators is the PHC's annual report
A plan is needed to ensure that the desired inputs of facility, trained
staff, and equipment are in place.
An illustrative list of available services indicators includes:
• number of immunization sessions (multipurpose camps)
planned and held;
• percentage of households visited;
• number of orientation camps organized; and
• percentage of subcenters with needed supplies.
-
Performance or Coverage Indicators
Performance or coverage indicators help answer the question: Have
the services been delivered? This question in turn consists of two parts:
Which services have been provided? What proportion of target seg
ments of the population have been covered? An illustrative list of cov
erage indicators includes the following:
• percentage of pregnant women registered;
• percentage of pregnant women receiving iron and folic acid
tablets;
• percentage of deliveries by trained persons;
• percentage of newborns weighed;
• percentage of contraceptive acceptors using permanent or
spacing methods; and
• number of RTIs and STDs detected, treated, or referred.
The usual source for the performance or coverage indicators
would be the worker reports or surveillance data.
Quality Indicators
I
Quality of care for reproductive health services has many dimensions,
as shown in Table 17.2. Although all these dimensions require atten
tion, it may be useful, when instituting a process of quality improve
ment, to begin by emphasizing counseling, follow-up, and technical
aspects of services.
An illustrative list of quality indicators includes:
• Counseling
- average time spent with a client
- percentage of contraceptive users who know about side
effects
- percentage of couples who received reproductive health
counseling
• Follow-up
- percentage of clients who know when they should return
for service
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362
Developing an Alternative System of Monitoring Indicators
- percentage of sterilization clients visited at home by the
health worker within one week of the procedure
• Technical
- percentage of providers who know about proper practices
- percentage of procedures that meet specified standards
- percentage of procedures in which aseptic conditions were
maintained
The data for these indicators come from observations of service
provision and interactions between the service provider and clients,
and from client feedback and provider interviews. Many dimensions
of quality cannot be measured quantitatively and require qualitative
measures. For instance, measuring the interpersonal dimension of
quality requires judgment by observers. The extent to which a pro
gram meets the needs of women as well as men can be assessed in
part by the involvement of clients in program planning, implementa
tion, and evaluation. How well the organization of service delivery
addresses men's and women's concerns and responds to their social
situation is another indicator of met or unmet need.
Outcome Indicators
An illustrative list of indicators for assessing whether reproductive
and child health services are having the desired outcomes includes
the following:
• number of deaths from vaccine-preventable diseases;
• neonatal mortality rate;
• percentage of hospital admissions with abortion-related com
plications; and
• STD prevalence.
Considerable debate remains, however, about the output and
outcome indicators for family planning services. Some illustrative in
dicators are:
• contraceptive prevalence;
• continuation rates for spacing methods;
• percentage of parity-four or higher-order births;
• percentage of births to women under age 20 or over age 35; and
• total fertility rate.
Generally the sources for these data are annual updates of ANM
registers and special surveys. However, there is still an absence of con-
Jay Satia • Sangeeta Subramanian Sokhi
363
TABLE 17.2
Dimensions of quality of care for reproductive health services
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Service delivery
Does the constellation of reproductive and child health services meet client needs?
Is there an Informed choice about contraceptive methods?
Is there adequate follow-up for continuity of use?
Are there effective referral linkages?
H ||
Information
Do clients receive comprehensive reproductive health education?
Are they sufficiently informed about the side effects of contraception and how to
address them?
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Technical
Are the service providers technically competent?
Do they use sound and appropriate technical practices?
Do they take universal precautions for asepsis?
Interpersonal
How much time is spent on clients?
How much care is shown them—for example, are they listened to and counseled?
Do clients have privacy?
Are they treated with dignity?
Social
Are services designed to meet the needs of both men and women?
Is there male involvement in responsible sexual behavior?
Do women have roles in program decisionmaking?
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sensus about what the impact indicators should be for some of the repro
ductive health service components, such as the prevention and treatment
of RTIs, HIV/AIDS, and other STDs, and how they should be measured.
The Way Forward
A number of issues remain to be addressed. In addition, action will be
required on two fronts: (1) implementing an alternative system of indi
cators; and (2) continuing to refine the new system as experience is gained.
Remaining Issues
Should the system of indicators be different for different geographic areas?
Different states and districts within each state are at various stages of
infrastructural development and performance. Therefore, it is reason
able to argue that the system of indicators should accommodate those
differences. For instance, where small-family norms are well institu
tionalized, such as in Tamil Nadu or Andhra Pradesh, it may make
sense to focus on quality-of-care indicators for family planning. On the
other hand, if poor access and availability of services still constrain their
J i/4
developing an Alternative System of Monitoring Indicators
use, as in Uttar Pradesh, it may be prudent to retain a greater empha
sis on coverage indicators. Different areas may also emphasize differ
ent quality-of-care indicators, although there is evidence that one indi
cator, increased client orientation, leads to improvement everywhere
All health services need to emphasize counseling, but the services with
inadequate technical quality of care may be wise to give greater em
phasis to technical aspects than to interpersonal counseling.
In addition, the various states have been classified into three per
formance categories on the basis of certain family planning and MCH
indicators such as the birth rate, proportion of births that take place
in institutions, and the proportion of births attended by trained at
tendants. The emphasis on indicators may differ depending upon the
category. In areas where access and availability of services are low,
the relative emphasis on coverage is high and that on unmet need and
quality of care low. In areas with moderate coverage, emphasis may
be placed on unmet need and the quality of care. Quality of care re
ceives the greatest emphasis where the access and availability of serv
ices are good and reasonable coverage levels have been achieved.
Should development be phased? There are two ways to bring about
change. One school argues that it is best to make a clean break. An
other school suggests gradual or phased development. The clean
break approach causes large disruptions, but it is usually acceptable
when there is a consensus that a crisis exists and the only solution is
a clean break from the past. As key stakeholders in a program rarely
share such a view, it is perhaps best to have a phased development.
For instance, in an area requiring change, the program could first
emphasize coverage measures (e.g., contraceptive prevalence or immunization coverage) for monitoring performance and subsequently
replace them with unmet-need and quality indicators.
What changes in management information systems would be needed?
Any alternative system should not impose undue burdens of data
collection. Indeed, the burden of data collection is already so high
that most stales are seeking ways to simplify it and reduce the num
ber of registers by using more comprehensive ones such as family
registers. However, as already discussed, the experience to date indi
cates that it may be possible to make the transition and in the process
simplify the management information system.
What changes would be needed in supervision? Perhaps a move to a
client-centered, quality approach has the greatest effect on the content
Jay Satia • Sangeeta Subramanian Soklo.
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and style of supervision. The supervisors would have to perform al
least four roles while de-emphasizing their monitoring role. They should
(1) provide technical updates and on-the-job training; (2) carry out qual
ity-assurance functions; (3) seek feedback from clients; and (4) compile
some data themselves rather than rely exclusively on workers' reports.
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implementing and Refining the Alternative System
a1
The government's task force has made recommendations for an al
ternative system of indicators. The implementation of an alternative
system would require: (1) creating a consensus on the use of the al
ternative system; (2) providing technical support to implement it; and
(3) training all involved in its use. Creating a consensus on the use of
the alternative system would require holding workshops or using
regularly scheduled meetings to explain the background and ration
ale for the alternative system. As for technical support, the state would
have to assist the districts, which in turn would have to assist the
PHCs, in making supportive changes in their management systems.
This might entail preparing plans, reorganizing the work, changing
the content and style of supervision, and streamlining the manage
ment information system. Training will be required in data collec
tion, analysis, and use at all levels.
In addition, to begin the phased development of indicators, pro
gram managers will have to learn from field experiences and pass
this knowledge on to lower-level staff. Three steps are required: (1)
documenting the implementation experience; (2) reviewing this ex
perience each year; and (3) making necessary changes in light of this
review. Adopting a client-centered quality-of-care approach will not
be easy, nor will it occur quickly. There is a need to recognize it for
what it is—a fundamental change in both program emphasis and in
the process by which this new emphasis is brought about.
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Acknowledgments
This chapter is a revised version of a background paper for the Workshop on Qual
ity Indicators for Reproductive and Child Health, organized by the Government of
India, the United Nations Population Fund (UNFPA), and the International Coun
cil on Management of Population Programmes (ICOMP), which took place in New
Delhi, 1S-19 March 1996. Support from the Ford Foundation made ICOMP's in
volvement in this workshop possible.
H
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366
Developing an Alternative System of Monitoring Indicators
Notes
1
2
3
RUWSEC provides comprehensive reproductive health education and serv
ices to women, adolescents, and men in approximately 100 villages in Tamil
Nadu. Its activities include community-based action for health promotion
and women's development, youth programs, a program for men, dissemi
nation of health-education materials, action research, and a reproductive
health clinic.
Anrudh Jain has developed an index called Helping Individuals Achieve
Their Reproductive Intentions (HARI), which he defines as 100 minus the
percentage of women who have an unplanned birth (for spacers) or an un
wanted birth (for limiters) during a specified period (e.g., 24 months). This
index of unmet need is difficult to implement. Moreover, it does not take
into account the unmet need of others, such as dissatisfied contraceptive
users and young persons.
r
In Egypt after a pilot test, the Ministry of Health has begun to implement a
program to improve the quality of reproductive health care. Four times a
year, a team of supervisors rates each service-delivery point on selected quality dimensions: equipment, facilities, commodities, infection prevention cli
ent registration and history-taking, counseling, IEC, home visits and follow
up, maintenance of records and reports, clinic operations, achievement of
service-delivery targets, and client satisfaction. The supervisors then develop
an action plan for improving the quality rating of the service-delivery point
in collaboration with the staff. These ratings are made widely known, creat
ing considerable peer pressure on staff to improve the rating of their own
service-delivery point. The entire process is repeated every quarter.
Jay Satia • Sangeeta Subramanian Sokhi
Mishra, A. 1995. Concept note on the Reproductive and Child Health Project.
Draft prepared for the Department of Family Welfare, Ministry of Health
l
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r
and Family Welfare, New Delhi.
.... u.
Murthy, N. and A. Barua. 1996. "Integrating reproductive health in health
programmes in India," paper presented at the International Conference on
Gender Perspectives in Population, Health and Development, sponsored
by MacArthur Foundation, New Delhi, January.
Nataraj S. 1994. "The magnitude of neglect: Women and sexually transmitted
diseases in India," in Private Decisions, Public Debate: Reproduction and Popu
lotion, eds. J. Mirsky and M. Radlett. London: Panos Publications, pp. 2-20.
Ravindran, S. 1994. Report from the National ICPD (International Conference
oh Population and Development) Preparatory Meeting, no. 2, Tamil Nadu,
India, sponsored by United Nations Population Fund and held at the Ru
ral Women's Social Education Centre, Chengalpattu, Tamil Nadu.
Satia, J.K. and S.J. Jejeebhoy (eds.). 1991. The Demographic Challenge: A Study of
Four Large Indian States. Bombay: Oxford University Press.
Satia, J.K., D. Mavalankar, and B. Sharma. 1994. "Micro-level planning using
rapid assessment for primary health care services," Health Policy and Plan
ning 9(3): 318-330.
Vikalp. 1996. Untitled presentation at a National Consultation on Family Wel
fare Programme in an Alternative Perspective, New Delhi.
World Health Organization (WHO). 1994. Indicators to Monitor Maternal Health
Goals: Report of a Technical Working Group, WHO Document WHO/FHE/
MSM/94.1. Geneva: WHO.
References
Bose, A. 1988. From Population to People. New Delhi: B. R. Publishing.
Foo, Gillian H.C. 1996. A Synthesis of Research Findings on Quality of Services Within
the Indian Family Welfare Programme. New Delhi: Population Council
Government of India (GOI). 1996. Circular of 9 February on target free approach
in Family Welfare Programme. New Delhi.
Government of India (GOI). Department of Family Welfare. 1995. Draft concept
note on the Reproductive and Child Health Project. New Delhi
Graham, Wendy and Sarah MacFarlane. 1996. "Guidelines for selecting repro
ductive health indicators," unpublished report commissioned by the World
Health Organization, Geneva.
indian Counci! of Medical Research (ICMR). 1991. Evaluation of Quality of Family
Services at Primary Health Centre Level: An ICMR Task Force Study
New Delhi: ICMR.
International Institute for Population Sciences (UPS). 1995. National Family Health
Family PlanninZ>: India' 1992-93. Bombay (Mumbai): UPS
Nfangal, D.K;1997. "Integrating RTI treatment in PHCs: The experience of Bundi
District, case study written for the Workshop on Leadership and Manage
ment Development for Reproductive Health, organized by International Coun
cil on Management of Population Programmes (ICOMP), Vellore, Tamil Nadu.
367
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Contributors
Sunita Bandewar is a Research Officer at the Centre for Enquiry into
Health and Allied Themes, Pune, where she heads a research and ad
vocacy program to improve the quality of abortion care. Ms.
Bandewar has been involved in a number of community-based re
search programs, such as rural development communication.
Sandhya Barge is an Associate Director of the Centre for Operations
Research and Training, Vadodara. Dr. Barge's interest is in social sci
ence research, with special emphasis on reproductive health, HIV/
AIDS, and quality of care, and in strengthening the capacity of NGOs
to address these issues.
Jagdish C. Bhatia is Chairman, Foundation for Research and Educa
tion in Health Management, Bangalore, an NGO dedicated to the im
provement of health services management. At the time of the study
he was at the Indian Institute of Management, Bangalore. Professor
Bhatia has published extensively in demography, health economics,
and health and population program management.
R. B. Gupta is an evaluation specialist at the State Innovations in Fam
ily Planning Services Agency (SIFPSA), Lucknow. Before joining
SIFPSA, Dr. Gupta was an evaluation expert for the Population Coun
cil, India. He works in the areas of demography, family planning, and
maternal and child health, and focuses on project evaluation meth
odologies. Dr. Gupta has extensive research and teaching experience
and is author/editor of several books.
Manisha Gupte is a founding member of MASUM, a grassroots
women's organization in rural Maharashtra. At the time of the study
she was a Senior Research Officer at the Centre for Enquiry into Health
and Allied Themes, Pune, and is currently on its board of trustees.
3b
Ir
370
m
Contributors
Contributors
Aditi Iyer is the working editor of Radical Journal of Health and a con
sultant on health research. Earlier Ms. Iyer worked at the Centre for
Enquiry into Health and Allied Themes, Mumbai, a nonprofit health
research institute, and at the Foundation for Research in Community
Health, Mumbai. She has done research in the areas of women in
health care, medical ethics, and tuberculosis.
Nirmala Murthy is President of the Foundation for Research in Health
Systems, an NGO located in Ahmedabad. Ms. Murthy directs pro
grams in operations research that focus on strengthening the man
agement of health services in Maharashtra. She has worked exten
sively on designing health information systems to improve the
planning, monitoring, and evaluation of health care services.
1
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Amar Jesani is Coordinator, Centre for Enquiry into Health and Al
lied Themes, Mumbai. Dr. Jesani is involved in research and advo
cacy in women's health, medical ethics, and human rights. He is Vice
Chairperson of the Forum for Medical Ethics Society and a coeditor
of its journal. Issues in Medical Ethics. Earlier, he was a Senior Research
Officer at the Foundation for Research in Community Health,
Mumbai.
M. E. Khan is Regional Advisor for Asia and the Near East at the
Population Council, Dhaka, Bangladesh. Earlier, Dr. Khan was Coun
try Director of the Population Council's New Delhi office. Dr. Khan
has extensive research experience in family planning, reproductive
health, sexual behavior, gender, and male involvement. He has spe
cialized in qualitative and quantitative research methodologies.
Michael A. Koenig is Associate Professor in the Department of Popu
lation and Family Health Sciences at the Johns Hopkins University
School of Hygiene and Public Health. At the time this volume was pre
pared, he was a Program Officer in Reproductive Health with the New
Delhi office of the Ford Foundation. For the past 15 years he has been
engaged in applied research on the issues of family planning, child sur
vival, and reproductive health in South Asia, and on the design of com
munity-based programs to address these health issues.
Dileep Mavalankar is Chairperson of the Public Systems Group at
the Indian Institute of Management, Ahmedabad. His background is
in medicine and public health. His areas of interest are reproductive
health management, quality of care, and microlevel planning in pri
mary health care.
Ambrish Mehta is a founding member of Action Research in Com
munity Health, an NGO located in rural Gujarat.
Anil Patel is a public health physician and epidemiologist and a
founding member of Action Research in Community Health, an NGO
located in rural Gujarat. He has been involved in a range of health
and development issues, particularly the provision of rational and
affordable health services.
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Bella C. Patel is a Program Officer at the Population Council, New Delhi.
Dr. Patel was previously associated with a program to improve the qual
ity and outreach of family planning and reproductive health services in
Uttar Pradesh. At present she coordinates a program in Gujarat that
builds and strengthens research capabilities in women's health. She works
in the areas of women's health, adolescent sexuality, and quality of cans
using qualitative and quantitative research methodologies.
Daxa Patel is an obstetrician/gynecologist and a founding member
of Action Research in Community Health (ARCH), an NGO located
in rural Gujarat. She is responsible for the community-based women's
health and reproductive health program run by ARCH.
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371
Hemlata Pisal is a Junior Research Officer at the Centre for Enquiry
into Health and Allied Themes, Pune. She has worked in tribal and
rural communities on health research and intervention programs.
Lakshmi Ramachandar is a consultant on reproductive health and is
conducting research on abortion services. At the time of the study
she was a Senior Research Executive with the Centre for Operations
Research and Training, Baroda.
T. K. Sundari Ravindran is the Honorary Executive Director of the
Rural Women's Social Education Centre, a grassroots women's organ
ization in Tamil Nadu. From 1992 through 1998 she was coeditor el
the journal Reproductive Health Matters. She is an activist-resea rd ici
on women's health and their reproductive health and rights and is
based in Delhi.
372.
Contributors
T. K. Roy is Professor and Head of the Department of Population
Policies and Programmes at the International Institute for Population
Sciences, Mumbai. Dr. Roy coordinated the National Family Health
Survey and has worked in family planning evaluation and national
exercises on target setting.
Jay Satia is Executive Director of the International Council on Man
agement of Population Programmes (ICOMP), based in Malaysia, an
organization dedicated to improving the management of population
programs. Earlier, Mr. Satia was a Professor at the Indian Institute of
Management, Ahmedabad.
Bharh Sharma is a Research Associate at the Indian Institute of Man
agement, Ahmedabad, and works in the area of operations research
and training among NGOs. Earlier, she worked at IDEAL, an NGO
based in Ahmedabad.
Sangeeta Subramanian Sokhi is a consultant with the International
Council on Management of Population Programmes in Malaysia,
based in India. She has worked extensively on the management of
reproductive health programs, institutionalizing quality of care, and
making health programs client- and gender-sensitive.
John W. Townsend is a Senior Associate and Director of the Fron
tiers in Reproductive Health Program with the Population Council
in Washington, D.C. Fie has extensive experience in designing and
conducting operations research in developing countries, and has
worked for the past 25 years in Latin America and South Asia.
Ravi K. Verma is a Reader at the International Institute for Popula
tion Sciences, Mumbai. He is also Principal Investigator of a project
on capacity-building initiatives in reproductive health. Dr Verma has
worked extensively in family planning and health program evalua
tion, quality of care, and men's sexual health concerns.
Leela Visana is an independent researcher. She is involved in field
based research on such issues as health, family planning, education,
and demographic transition. Currently, Dr. Visaria is engaged in re
search on gender issues, including the reproductive health of women,
population policy options, and domestic violence.
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