Sustainability. Quality INDIA USAID. Access. Equity. Capacity Building of Institutions in the Health Sector. Generating Demand. Scale-up APRIL 2012

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1 USAID UNITED STATES AGENCY INTERNATIONAL DEVELOPMENT USAID FROM THE AMERICAN PEOPLE INDIA Sustainability Equity Generating Demand Access Quality Scale-up Capacity Building of Institutions in the Health Sector Review of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand The Power of Innovations and Partnership APRIL 2012 This publication was prepared for review by the United States Agency for International Development. It was prepared by Futures Group International.

2 Photo credits: Jignesh Patel, Gaurang Anand, Satvir Malhotra and Health Policy Project Suggested citation: IFPS Technical Assistance Project (ITAP) Capacity Building of Institutions in the Health Sector: Review of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand. Gurgaon, Haryana: Futures Group, ITAP. The IFPS Technical Assistance Project is funded by the United States Agency for International Development (USAID) under Contract No. GPO-I-0I I500, beginning April 1, The project is implemented by Futures Group International in India, in partnership with Bearing Point, Sibley International, Johns Hopkins University, and QED. For further information, contact: Futures Group International, DLF Building No. 10 B, 5th Floor, DLF Cyber City, Phase II, Gurgaon

3 Capacity Building of Institutions in the Health Sector Review of Experiences in Uttar Pradesh, Uttarakhand and Jharkhand The Power of Innovations and Partnership APRIL 2012 The author s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

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5 USAID UNITED STATES AGENCY INTERNATIONAL DEVELOPMENT USAID FROM THE AMERICAN PEOPLE FOREWORD INDIA FOREWORD India has made significant strides in improving its health indicators over the last few decades. Introduction of the National Rural Health Mission (NRHM) in 2005 further reinforced its commitment to improve health indicators and achieve the universal Millennium Development Goals. The United States Agency for International Development (USAID) has been a strong and committed partner as India strives to improve its family planning and reproductive health indicators across the country. USAID, in collaboration with the Government of India, launched bilateral Innovations in Family Planning Services (IFPS) Project in 1992 to design, test and expand innovative approaches for improving quality of and access to family planning and reproductive and child health services, particularly for women, rural populations, and other underserved groups. Support for developing and strengthening individual and institutional capacity has been the mainstay of all USAID programming, reflected in the implementation efforts of the IFPS Project. Programs as well as technical assistance were designed to support state societies and address their capacity needs in implementing NRHM, while generating evidence on innovative approaches to achieve health objectives. The IFPS Project has worked in close partnership with Indian institutions to build capacities of people and develop systems for quality assurance, training, strategic behavior change communication, monitoring and evaluation, and other aspects to improve health management. These efforts have paved the way for shaping leading institutions that can contribute tremendously in the implementation of health programs. This volume is a summary of the various initiatives undertaken during the course of implementation of the IFPS Project to foster, lead and manage the capacity building process to improve performance of health services. USAID hopes that this compilation will further inform state governments and institutions in their capacity building efforts. Kerry Pelzman Director Health Office U.S. Agency for International Development American Embassy Tel: Chanakyapuri Fax: New Delhi

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7 CONTENTS Acknowledgements Abbreviations Executive Summary vii viii x 1. INTRODUCTION Purpose and Organization of the Report 3 2. ANALYSIS OF NEEDS 4 3. COLLABORATIONS AND SUPPORT AT THE NATIONAL LEVEL Series of Collaborations with National Institute of Health and Family Welfare Laying the Foundation for National Health Systems Resource Center 9 4. BUILDING CAPACITIES OF THE STATE INSTITUTES OF HEALTH AND FAMILY WELFARE About State Institutes of Health and Family Welfare Support to Establish and Build Capacities for Sustainable SIHFW: Uttarakhand and Uttar Pradesh Setting the Stage in Jharkhand TECHNICAL SUPPORT FOR IMPLEMENTATION OF NRHM IN UTTARAKHAND AND UTTAR PRADESH Support to SHSRC in Uttarakhand Strengthening Systems for Decentralized Planning Capacity Building of Rogi Kalyan Samitis in Uttarakhand SUSTAINABLE INSTITUTIONS TO BRING HEALTH CLOSER TO THE PEOPLE Support for Creation of State ASHA Resource Center and District ASHA Resource Centers SETTING UP MECHANISMS FOR QUALITY ASSURANCE Quality Assurance Mechanisms and Programs Quality Assurance for PPP Models Quality Improvement Processes for RCH Camps in Jharkhand SIFPSA: LEAVING BEHIND A LEGACY Creation of an Autonomous Body for Implementation of IFPS Project in Uttar Pradesh Drawing an Organizational Framework for the Society 25 Contents v

8 8.3 Performance Based Disbursement Mechanism Building Capacities and Providing Technical Assistance for a Sustainable Society Transitioning and Re-aligning itself through the Course of the IFPS Project Key Issues Affecting SIFPSA s Operations Elements of Success Addressing Complexities for SIFPSA s Course Ahead STRENGTHENING INSTITUTIONS TO PROMOTE FAMILY PLANNING IN JHARKHAND BUILDING CAPACITIES OF THE PRIVATE SECTOR Identifying and Building Local Capacities Enhancing Capacities of the Private Facilities for Provision of Quality Services Evidence-based Planning, Design and Implementation of Programs Orienting Advertising Agencies to the Development Sector CHALLENGES AND WAY FORWARD 38 REFERENCES 39 List of TABLES Table 1: Summary of Courses in Collaboration with NIHFW 7 Table 2: Summary of the Training and Content Development Support to SIHFW 12 Table 3: Clinical Trainings conducted in Uttar Pradesh as part of the IFPS Project ( ) 29 Table 4: A Summary of the BCC initiatives under the IFPS Project in Uttar Pradesh ( ) 30 Table 5: By the Numbers: Family Planning Fortnight 33 List of FIGURES Figure 1: Capacity Building Framework: IFPS Project 2 Figure 2: State ASHA Support System 19 Figure 3: Organizational Structure of the State Innovations in Family Planning Services Agency 26 vi Capacity Building of Institutions in the Health Sector

9 ACKNOWLEDGMENTS This report documents the efforts and contributions made by USAID through the Innovations in Family Planning Services (IFPS) Project towards capacity building and strengthening of public and private institutions in the health sector in India. The report highlights the support rendered at the national level and in three Indian states: Uttar Pradesh, Uttarakhand, and Jharkhand. The USAID funded IFPS Project is a joint US-India initiative that has worked to promote improved family planning and reproductive health for India s poor communities and works in close collaboration with Ministry of Health and Family Welfare, Government of India as well as with state societies in Uttarakhand, Uttar Pradesh and Jharkhand. The project would like to acknowledge the collaborative efforts of the public health institutions including the Ministry of Health and Family Welfare, Government of India, state governments, apex national and state institutes (National Institute of Health and Family Welfare (NIHFW), State Institute of Health and Family Welfare (SIHFW), National Health Systems Resource Center (NHSRC) and State Health Systems Resource Centers (SHSRCs), State Program Management Units (SPMUs) and District Program Management Units (DPMUs) for National Rural Health Mission (NRHM) implementation at the state level, state societies (State Innovations in Family Planning Services Agency (SIFPSA), Uttarakhand Health and Family Welfare Society (UKHFWS) and Jharkhand Health Society (JHS) and district counterparts and several private institutions, including private health facilities, nongovernment organizations, research organizations and other creative agencies. These collaborations have resulted in strengthening of these institutions to contribute to the overall health systems strengthening in the country. We would also like to acknowledge the technical leadership and guidance provided towards the capacity building efforts by the USAID India Mission, especially Dr. Loveleen Johri, Shweta Verma and Vijay Paulraj. Tanya Liberhan, IFPS Technical Assistance Project (ITAP) (Futures Group), compiled this report with constant guidance and support from Dr. G Narayana and Shuvi Sharma. The report has been put together drawing uponseveral interviews with project staff and partners, and a range of published and unpublished project reports, documentation and databases. Several individuals contributed to the drafting of this report, including Dr. Gadde Narayana, Shuvi Sharma, Ashutosh Kandwal, Dr. Ajay Misra, Dr. Santosh Singh, and Dr. Nimisha Goel. This report has been reviewed by Dr. G Narayana, Shuvi Sharma, Dr. Suneeta Sharma, and Dr. Nidhi Choudhry and their inputs have proved to be invaluable. Acknowledgments vii

10 ABBREVIATIONS AIDS ANC ANM ASHA BCC BHEO BPL CHC CHV CMO COPE DAP DARC DGHS DHAP DivPMU DPM DPMU DQAG EAG ED FOGSI FP FRU FWC GDP GHI GoI GoUK GoUP HIV HMS IEC IEC IFPS IPC IPH Acquired Immuno Deficiency Syndrome Antenatal Care Auxiliary Nurse Mid-wife Accredited Social Health Activist Behavior Change Communication Block Health Education Officer Below Poverty Line Community Health Center Community Health Volunteer Chief Medical Officer Client Oriented and Provider Efficient District Action Plan District ASHA Resource Center Director General Health Services District Health Action Plan Divisional Program Management Unit District Program Manager District Program Management Unit District Quality Assurance Group Empowered Action Group Executive Director Federation of Obstetric and Gynecological Societies of India Family Planning First Referral Unit Family Welfare Counselor Gross Domestic Product Global Health Initiative Government of India Government of Uttarakhand Government of Uttar Pradesh Human Immuno Virus Hospital Management Society Information Education and Communication Information, Education, and Communication Innovations in Family Planning Services Interpersonal Communication Institute of Public Health viii Capacity Building of Institutions in the Health Sector

11 IPHS ITAP IUCD JSK LHV MCH M&E MDG MGHN MIS MNGO MoHFW NABH NGO NHSRC NIHFW NRHM NSV PBD PERFORM PHC PHFI PIP PMV PPP PRI QA QI RCH RH RKS SARC SHSRC SIFPSA SIHFW SNMC SPMU TAG ToT UKHFWS UP USAID USG Indian Public Health Standards IFPS Technical Assistance Project Intrauterine Contraceptive Device Jansankhya Sthirata Kosh Lady Health Visitor Maternal and Child Health Monitoring and Evaluation Millennium Development Goal Merrygold Health Network Management Information Systems Mother Nongovernmental Organization Ministry of Health and Family Welfare National Accreditation Board for Hospitals and Health Care Providers Nongovernmental Organization National Health Systems Resource Center National Institute of Health and Family Welfare National Rural Health Mission No-scalpel Vasectomy Performance Based Disbursement Program Evaluation Review for Organizational Research Mangement Primary Health Center Public Health Foundation of India Program Implementation Plan Project Management Unit Public-Private Partnership Panchayati Raj Institution Quality Assurance Quality Improvement Reproductive and Child Health Reproductive Health Rogi Kalyan Samiti State ASHA Resource Center State Health Systems Resource Center State Innovations in Family Planning Services Agency State Institute of Health and Family Welfare Sarojini Naidu Medical College State Program Management Unit Technical Advisory Group Training of Trainers Uttarakhand Health and Family Welfare Society Uttar Pradesh United States Agency for International Development United States Government Abbreviations ix

12 EXECUTIVE SUMMARY Capacity building has been one of the most important approaches used by international development organizations to achieve development objectives worldwide. It focuses on understanding the obstacles that inhibit people, governments, international organizations and nongovernmental organizations (NGOs) from realizing their developmental goals, while enhancing their abilities to achieve measurable and sustainable results. Capacity building takes place at three levels, individual, institutional, and societal. At the institutional level capacity building involves creation of new institutions or strengthening of existing institutions while at the individual level, it deals with development of conditions that allow individual participants to build and enhance their existing knowledge and skills. The United States Agency for International Development (USAID) has been committed to support and strengthen capacities at individual and institutional levels through one of its early projects in India. USAID and the Government of India (GoI) collaborated to implement the Innovations in Family Planning Services (IFPS) Project, from The project, in its first phase, focused on improving quality, access and demand for family planning (FP) and reproductive health (RH) services in Uttar Pradesh, while shifting its priorities in its second phase to developing, demonstrating, documenting and leveraging expansion of public-private partnerships (PPPs) for provision of high quality FP and RH services in three states of north India (UP, Uttarakhand and Jharkhand) and certain activities at the national level. In its capacity building efforts, the project has mainly focused on providing technical assistance to build capacities of key systems and strengthen local institutions in areas such as quality assurance (QA), training and human resource deployment, supervision, monitoring and evaluation, planning at the national, state, and district levels, and behavior change communication (BCC). At the national level, the IFPS Project has formed key linkages and collaborations with Indian technical organizations. A series of collaborations were formed with the National Institute of Health and Family Welfare (NIHFW) to design and conduct effective courses for health program managers on PPPs and decentralization of health systems. The IFPS Project has also provided technical assistance and support for creation and establishment of the National Health Systems Resource Center (NHSRC). Besides these efforts, significant technical expertise of health professionals has been extended to the Ministry of Health and Family Welfare (MoHFW). At the state level, support has been extended to establish and build capacities of the State Institutes of Health and Family Welfare (SIHFW) in Uttarakhand and Uttar Pradesh and the Institute for Public Health (Jharkhand). Specifically for Uttarakhand, the IFPS Project supported development of the organizational structure, administrative and management systems, financial management systems and human resource policies for the SIHFW. For UP, the support has been at three levels designing training programs for health providers, conducting training, and development of training aids. The state level societies established to enable implementation of the National Rural Health Mission (NRHM) were supported by the IFPS Project to strengthen systems for decentralized planning. The states have established two units for better implementation of the Mission, i.e., State Health Systems Resource Center (SHSRC) to support innovations and monitoring and State Program Management Units (SPMU) and District Program Management Units (DPMUs) for program management. The project has supported NRHM program management units at state and district levels for preparation of District Action Plans (DAPs) as well as state Program Implementation Plans (PIPs) in Uttarakhand, Jharkhand and UP. Significant contributions have also been made through the course of the project to strengthen capacities x Capacity Building of Institutions in the Health Sector

13 and establish systems at the micro level to bring health closer to people. This has been in the form of support for creation of State ASHA (accredited social health activist) Resource Center (SARC) and District ASHA Resource Centers (DARCs) in Uttarakhand to strengthen the ASHA support system in the state. This resulted from the successful implementation of one of the PPP models implemented as part of the IFPS Project i.e., ASHA Plus program. The project has also supported institutionalization of key mechanisms, as part of the pilot projects initiated through the course of its implementation. QA mechanisms, developed through the course of implementation of the projects in UP and Uttarakhand, will now support these states in improving the quality of service provision. These include: the QA Cell, district quality assurance groups (DQAGs) established at the state and district levels, trained health officials, a better equipped SHSRC or state level QA Cell to conduct further trainings, and mobilized health facilities trained on infection prevention practices, emergency preparedness and biomedical waste management. Also, the capacities of the private sector have been strengthened to ensure quality provision as a result of close collaborations during the implementation of some of the PPP models. The IFPS Project has been implemented through autonomous state health societies, the State Innovations in Family Planning Services Agency (SIFPSA) in UP, the Jharkhand Health Society in Jharkhand and the Uttarakhand Health and Family Welfare Society (UKHFWS) in Uttarakhand, in close collaboration with the respective state governments.these autonomous societies were created to guide all project activities. SIFPSA was established during the first phase of the project in 1993, when the focus was on UP. Through the course of the project, with technical assistance and experience of implementing effective programs, SIFPSA has become an established resource for FP and RH and program implementation for the state of UP. Strong foundation has been established to take the FP program forward in Jharkhand. The IFPS Project supported the state to set up the FP Task Force, envisioned to cater to specific needs and to add value to the overall family planning endeavor at the state level. One of the mandates of the Task Force was to set up an FP Cell and develop the FP strategy for the state. The project supported the state in these activities and other activities including development of state guidelines on FP and development of information, education and communication (IEC) material on FP. Several collaborations and partnerships were established with the private sector through the implementation of the IFPS Project. Identification of key local partners and building their capacities to support program implementation and coverage was an important aspect of the IFPS Project. Several NGOs were involved, oriented, and mentored to support implementation of the PPP models in the three states. Similarly, the capacities of the private sector health providers who were part of the collaborations for implementation of certain PPP models were enhanced for provision of quality services. The project was also able to orient and strengthen capacities of research organizations and several advertising agencies through the course of its implementation. Along the way, the project addressed certain complexities and challenges working closely with state governments, autonomous institutions, state government support structures, NGOs and other private organizations such as frequent changes in leadership, administrative complexities, narrow perspective to capacity building and getting a consensual buy-in from all stakeholders. The project tapped all opportunities to strengthen the existing and new institutions, establish systems and build individual capacities to ensure sustainable institutions and enhance government ownership. The systems established as part of these institutions are envisioned to continue to meet their objectives even after the IFPS Project efforts conclude. Key mechanisms and institutions can be potentially utilized for implementation of national and state government programs. Executive Summary xi

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15 Chapter 1 INTRODUCTION Till 1990s, most international organizations used institution building or institution strengthening or organizational development approaches to achieve the objectives of development programs. With a focus on sustainable development in the past two decades, the emphasis shifted to capacity building with an enhanced scope. Capacity building focuses on understanding the obstacles that inhibit people, governments, international organizations and nongovernmental organizations (NGOs) from achieving their goals while enhancing the abilities that will allow them to achieve measurable and sustainable results. Capacity building takes place on an individual level, institutional level and the societal level. At the individual level, capacity building deals with development of conditions that allow individual participants to build and enhance their existing knowledge and skills. It also calls for the establishment of conditions that will allow individuals to engage in the process of learning and adapting to change. These are achieved through a variety of mechanisms such as training programs, joint projects, sharing on-job experiences, understanding operations research, study tours etc. At the institutional level, capacity building involves creation of new institutions or strengthening of existing institutions. The main emphasis is on supporting institutions in forming sound policies, organizational structures, processes and procedures and effective methods of management and revenue control. At the societal level, capacity building supports a more interactive public administration that learns equally from its actions and feedback from the population at large. USAID commitment to capacity building The United States Agency for International Development s (USAID) commitment to help countries improve health outcomes through strengthened systems, specifically through capacity building, reflects in its latest efforts to promote health and development around the world. The United States Government (USG) Global Health Initiative (GHI) 1 launched in 2009, is the latest chapter in US efforts to promote health and development around the world. While the key principles of the initiative include, encouraging country ownership and investment in countryled plans, and building sustainability through health systems strengthening, the program has based itself upon BEST 2 (Best Practices for Family Planning, Maternal and Child Health, and Nutrition) action plan approach, which advocates supporting country capacity building and strengthening systems for sustained impact (Global Health Initiative, ghi/index.htm; factsheet.html). USAID s commitment to support and strengthen institutional development and capacities of health professionals in India reflects through implementation of one of its early projects in India i.e., the Innovations in Family Planning Services (IFPS) Project, a joint effort of the Government of India (GoI) and USAID/India that has spanned over two decades ( ). To begin with, the IFPS Project focused on improving quality, access, and demand for family planning (FP) and reproductive health (RH) services in Uttar Pradesh (UP). With the project moving in its next phase (2004), the priorities shifted towards developing, demonstrating, documenting and leveraging expansion of public-private partnerships (PPPs) for provision of high quality FP and RH services in three states of north India (UP, Uttarakhand and Jharkhand) and certain activities at the national level. The project strengthened the capacity of Indian institutions to implement FP/RH programs, builds the capacity 1 See 2 See Introduction 1

16 of clinical and community-level providers, reduces barriers to access quality FP/RH services, and increases awareness, demand, and use of FP/RH services. 3 Of the three major thrusts for IFPS Project, one of them has been to use all opportunities to build capacities with emphasis on the sustainability quotient (USAID Global Health Fellows Program, 2007). Considering that the strengthening process for both state level and local institutions requires more time to produce results, the technical support provided through the project period serves as the foundation for sustainable institutions, the larger objective being that these institutions will further provide technical support to the public and private health systems in the country. In this context, the IFPS Project has directed efforts to provide technical assistance to build capacities of key systems and strengthen local institutions, in areas such as technical skills development, quality assurance (QA), training and human resource deployment, supervision, monitoring and evaluation, planning at the national, state and district levels, and behavior change communication (BCC). In its focus on capacity building, the IFPS Project has mainly concentrated on individual and institutional level capacity building. The basic framework that defines the capacity building efforts of the project is presented in Figure 1. The framework evolved FIGURE 1: CAPACITY BUILDING FRAMEWORK: IFPS PROJECT Institutional Individual 3 See Develop organizational framework Staff development Support Systems Technical Assistance Training of trainers Monitoring and Supervision Direct training On the job training Exposure visits Mentoring Study tours Dependent Guided Assisted Independent Government at national, state and district levels NRHM at the state and district levels National and state autonomous bodies and quasi government institutes A P P R O A C H E S NGOs, private sector health providers, research organizations IDENTIFIED PARTNER INDIVIDUALS, ORGANIZATIONS AND INSTITUTIONS *Adapted components on staged capacity building from the Australian AID (2006) A Staged Approach to Assess, Plan and Monitor Capacity Building. through the three phases of the project and responded to the needs, shift in project priorities and reforms in the national health programs. The project employed a variety of capacity building approaches at both individual and institutional levels, including direct training, mentoring, and exposure visits for individual level capacity building, and developing the organizational structures and providing technical assistance for institutional level capacity building. A staged process of capacity building was envisioned, with the IFPS Project supporting and mentoring the institutions to be self-sustainable with key systems and mechanisms in place. For these efforts, along the implementation of the IFPS Project, several individuals, organizations and institutions were identified for collaborations and capacity building support. IFPS Project s support for capacity building to NRHM With the launch of the National Rural Health Mission (NRHM) in 2005, capacity building approaches for sustainable development have received a renewed rigor in India. NRHM was launched to facilitate architectural corrections in the basic healthcare system of India. It aimed to provide accessible, affordable and accountable quality health services to the poorest household in the remotest rural region by increasing the overall public expenditure on health from 0.9 percent to 2-3 percent of the GDP (NRHM, mohfw.nic.in/nrhm). The Mission recognized the need for an integrated approach to health-care service delivery. Improved management through capacity building at all levels is one of the main cornerstones 2 Capacity Building of Institutions in the Health Sector

17 adopted by NRHM, others include communitization, flexible financing, monitoring against standards and innovations in human resource management. In the initial phases of the NRHM, to support the intricate and multilevel Indian public health system that extends up to the village level, establishment of quasi-government institutions at all levels was initiated. The IFPS Project supported the establishment of these institutions at the national and state levels. At the national level, the IFPS Project supported the establishment of the National Health Systems Resources Center (NHSRC) and strengthening the National Institute of Health and Family Welfare (NIHFW). Structures such as the State Program Management Unit (SPMU), Divisional Program Management Units (Div.PMUs) and District Program Management Units (DPMUs) in the states, districts and blocks were being established. The project worked with a variety of stakeholders to strengthen capacities of individuals in government and nongovernment sectors and supported the state government efforts to establish or modernize the existing institutions. The state support systems for NRHM, specifically in Uttarakhand and UP, were established and mentoring support was further extended through the project. The IFPS Project has been facilitated by the formation and strengthening of autonomous state health societies. The project is being implemented through these societies, the State Innovations in Family Planning Services Agency (SIFPSA) in UP, Jharkhand Health Society in Jharkhand and Uttarakhand Health and Family Welfare Society (UKHFWS) in Uttarakhand, in close collaboration with the respective state governments. In support of this bilateral initiative, the IFPS Technical Assistance Project (ITAP), implemented by Futures Group, India and partners, facilitates multisectoral dialogue, strategic information analysis and use, in-country capacity building, and other implementation assistance. A major thrust for ITAP is to develop, design, demonstrate, document, and disseminate innovative models and financing strategies, including PPPs that reach the poor and vulnerable communities with FP and RH services. A major element distinguishing the IFPS Project from most other USAIDfinanced activities is the nature of its funding. Bilateral activities conducted under the IFPS Project are funded through a mechanism known as performance-based disbursement (PBD) (See Section 8 for details on PBD). 1.1 PURPOSE AND ORGANIZATION OF THE REPORT This report captures the contributions made by USAID through the IFPS Project, towards capacity building and strengthening of public and private institutions in the health sector in India, largely in its second and third phase. It intends to highlight the support rendered, lessons learned and recommendations developed over the course of IFPS Project and ITAP s work on institutional capacity building. It is hoped that these experiences will offer insights into the nuances of working with public health institutions, building capacities of private institutions to foresee their participation in the health sector and strengthening these institutions to contribute to the overall health systems strengthening in the country. Section 2 of the report presents the gaps related to institutional development and capacity building. Section 3 focuses attention on the series of collaborations and support initiated through the USAID funded IFPS Project, at the national level. Section 4 presents the capacity building initiatives for State Institutes of Health and Family Welfare (SIHFW) in the USAID priority states. Section 5 presents the technical support provided through the IFPS Project for implementation of NRHM program in the states. In section 6 and 7, the support provided to establish systems for management of community level workers and mechanisms for QA have been presented. Section 8 presents the journey of SIFPSA in UP. Contributions made to establish and strengthen institutions in order to promote FP in Jharkhand are summarized in Section 9. Section 10 pulls together all experiences of capacity building of private institutions, NGOs and individuals. Amongst contributions and significant achievements detailed throughout the report, there were challenges and lessons learned, and these have been presented in the last section. Introduction 3

18 Chapter 2 ANALYSIS OF NEEDS After the initiation of the IFPS Project, PERFORM 4 survey was conducted in 1995 to establish a baseline for the performance indicators of the project and generate evidence to inform project design. It was designed to measure the IFPS benchmark indicators required at three levels: (1) public and private service delivery points, (2) service providers and (3) client population. The survey provided a wealth of information on the status of family welfare services in the public and private sectors, among FP staff and about the utilization and future demand for those services by the eligible couples. The survey results provided an insight into how the levels of invested effort and resources into strengthening the family welfare service capacities of the government, nongovernment and commercial sectors should be revived. Focus on improvement in quality of service provision was identified as a key component to result in an increase in service utilization. The survey found that not enough FP staff at health facilities were trained on FP service procedures with only 44 percent of the staff at public health facilities and 14 percent at private facilities reported receiving training in the last five years (The EVALUATION Project, 1996). The readiness of health facilities and staff for high quality FP service provision could be questioned based on the survey findings. One of the key objectives of the IFPS Project in the initial phase was to strengthen capacities of staff and facilities with clinical and non-clinical training on FP, particularly contraceptive methods and client counseling. With the IFPS Project moving into its second phase in 2004, lack of provision of quality services still remained a challenge. Several other gaps were identified, which informed the objectives of the project s next phase. One of the gaps identified was the lack of adequately trained and skilled providers in both public and private health sectors. This affected the quality of service provision, which further led to lower utilization of services by the people. Also witnessed during that period was the lack of a strong institutional base to provide technical assistance to the health sector. Autonomous quasi-government institutions, nongovernmental organizations (NGOs), and private sector health institutions could significantly contribute to address these challenges for overall health systems development. These institutions could provide technical assistance to the health system by conducting research, analyzing health policies, human resource planning and management, training health professionals, quality assurance, planning, and monitoring and evaluation. In this context, it became important that these institutions be established, strengthened, trained and sustained. As the project moved into its second phase, the period was also marked by changes in the Indian healthcare system, with the introduction of the NRHM program. The program adopted new approaches such as flexible financing, monitoring against standards, improved management through capacity building, and innovations in human resource management as its main cornerstones. With a new thinking, new cadre of health workers, community based committees and new systems in place, a need was felt to bring in new structures to manage and monitor the program. Weak institutional capacity to support management and monitoring of the NRHM activities at state and district levels was a key challenge. This was also reflected in the materialization of decentralized planning, which was the principal pivot of the program. Therefore, for better planning and implementation at the state and district levels, new institutions of governance each at national, state, district, facility and village levels were to be created. Understanding these specific needs based on the health system scenario and the strategic programmatic shifts of the GoI, the IFPS Project in its second and third phase, prioritized to address these challenges through institutional strengthening and human capacity development. 4 Program Evaluation Review for Organizational Resource Management or PERFORM was designed and produced by The Evaluation Project of the University of North Carolina and served as one of the means of evaluation at the disposal of SIFPSA and USAID to ensure that the right and desired results are being achieved. 4 Capacity Building of Institutions in the Health Sector

19 Chapter 3 COLLABORATIONS AND SUPPORT AT THE NATIONAL LEVEL One of the core elements of the IFPS Project is to develop and strengthen key institutions in both public and private sectors. As part of the project, technical assistance activities were designed to form linkages with Indian technical organizations to deepen the already strong national capacity and develop the capacity of the state and national public health sector to partner with the private sector. The IFPS Project s mandate to strengthen these institutions has been comprehended at the national level through a series of collaborations with the NIHFW, support for creation and set up of NHSRC and significant human resource support to the Ministry of Health and Family Welfare (MoHFW). 3.1 SERIES OF COLLABORATIONS WITH NATIONAL INSTITUTE OF HEALTH AND FAMILY WELFARE NIHFW is an apex technical institute, to promote health and family welfare activities in the country. It is a quasigovernmental institution and works under the auspices of MoHFW, GoI. Established nearly three decades ago, the institute addresses a wide range of issues on public health and family welfare management through its multi-disciplinary functions in research, consultancy, education and training. In-service training of middle and senior level health personnel has been one of the core focus areas of the institute. NIHFW is the nodal agency for coordinating the capacity building and training component under NRHM for the entire country. The institute organizes a variety of training courses on reproductive and child health (RCH), Human Immuno Virus and Aquired Immuno Deficiency Syndrome (HIV and AIDS), reproductive biomedicine, adolescent health, geriatric care, geographic information system, PPP, health management, hospital administration, health communication, nursing administration, educational technology, health financing/economics, statistics and demography and other areas of public health. Currently, a total of 15 SIHFW established at the state level support NIHFW in this endeavor. The institute is also involved in several operations research, applied research and evaluation studies of health and family welfare programs. On the education front, NIHFW offers three regular post graduate courses on Community Health Administration and Health Administration, and Public Health Management. NIHFW collaborates with various international agencies which are also contributing towards improving the health scenario in the country, to apprehend the larger health goals. The IFPS Project has collaborated with NIHFW to design the first conference on PPPs in the health sector, courses on decentralization, several studies, and is supporting a position at NIHFW to coordinate all such activities. Designing the first public-private partnership conference One of the core areas for the IFPS Project was to develop, demonstrate, document and leverage expansion of working models of PPPs which deliver integrated FP and RH services. To substantiate upon its objective, the IFPS Project supported the GoI in developing a PPP strategy at the national level in early Several studies on various PPP models including contracting out, mobile health vans and professional associations such as Indian Medical Association, Federation of Obstetric and Gynegological Societies of India (FOGSI), Indian Nursing Association were conducted along with a literature review of some of the other PPP models (social franchising, voucher scheme, social marketing). Based on the study analyses and literature review, the PPP strategy was developed, which was later incorporated as part of the RCH II Program 5 Strategy. 5 RCH II Program: To help achieve reproductive and child health (RCH) objectives, particularly improving access for the poor, India designed the multi-year RCH-II program in 2005, which is now part of the NRHM. Collaborations and Support at the National Level 5

20 Following the development of the PPP strategy, it was important that these models be shared with representatives from different states. Therefore, in December 2005, the IFPS Project through ITAP collaborated with NIHFW to design the first conference on PPPs. The conference was designed to share PPP experiences from the entire country with policy makers, program administrators and researchers. The conference helped participants representing different states share their experiences on implementing various PPP initiatives. The effort provided insights to the members/faculty of the institute on the growing importance of PPPs for the health sector, and built their capacities to further design and implement PPP models. Collaboration for courses on public-private partnerships in the health sector NIHFW and the World Bank Institute are collaborating on a capacity development program to improve health systems policy and management. As part of this initiative, health training needs assessments were conducted in October 2007 in three focus states: Rajasthan, Orissa and UP, to identify the priority training needs of the selected states in the area of health system policy and management to ensure a more effective implementation of NRHM. The studies highlighted the need for further training at the state level on specific subjects such as PPP, human resource management and quality improvement in healthcare. Several development partners contributed to the effort, with USAID supporting the PPP training component. April 2008 through September 2011, five workshops on PPP were facilitated in a collaborative mode by USAID through the IFPS Project and NIHFW. The five day workshops oriented senior and middle level executives, and technocrats from state/district/below district levels of nine states (Rajasthan, Orissa, UP, Uttarakhand, Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand and West Bengal) on implementation of PPP initiatives. A specific PPP initiative was identified in each of these states and personnel working in that particular initiative were invited for the workshops. The PPP experts shared the mechanism to design and implement successful PPP models, and shared success stories from the PPP models implemented and prospective challenges during implementation. The workshops offered a platform for prolific discussions with key perspectives on implementation, client satisfaction, scope for improvement and potential for replication. The initial workshops ( ) had international experts on PPP, as key resource persons to conduct sessions and prepare course content. The course content, in collaboration with the faculty of NIHFW, materials and presentations were shared with the representatives of development partners. The courses conducted in a collaborative mode, built the capacities of the faculty and resource persons from other agencies to conduct such courses on PPP in the future. As a result, the last two courses ( ) were conducted by the faculty and resource persons from NIHFW without support from any external experts. NIHFW now has the necessary course materials and wherewithal to conduct PPP courses for health professionals in the country. Key resource persons for the training course on PPPs in Health Sector in Uttarakhand, 2011 Building capacities for Alternative Training Methodology for IUCD The IFPS Project efforts to mainstream intrauterine contraceptive devices (IUCD) began in its phase I activities in UP. Recognizing its importance, the MoHFW, GoI decided to revive and reposition IUCD in the country, particularly in Empowered Action Group (EAG) 6 Capacity Building of Institutions in the Health Sector

21 states 6 with low contraceptive prevalence rates. The effort was supported by the introduction of new IUCD technologies (380 A), which provided an opportunity to position and promote IUCD as both a limiting and a spacing method. All these efforts required an effective and quality oriented service delivery system, which would be ensured through quality training systems, and providers equipped with new skills and technology. The IFPS Project supported MoHFW to develop a separate IUCD Reference Manual for medical officers and nursing personnel, trainer s guide, and participants handbook for the providers, and also drafted the Guidelines for Repositioning IUCD in Family Welfare Program Strategy, Operational Plan and Achievements to roll-out the IUCD training, using skill-based classroom and online computer assisted learning approaches. NIHFW collaborated with USAID through the IFPS Project for capacity building of program managers and service providers on an alternative training methodology for IUCD insertion. The expected outcome of the training was to develop the competency of service providers on the anatomical models for IUCD insertion and removal before they practice on clients. A humanistic way of training using the Pelvic (ZOE) models was imparted to enable the trainees to acquire competency in insertion of IUCD using the no-touch and withdrawal techniques without any fear of injuring the client. Representatives from MoHFW and, program managers and service providers from 12 states (identified region-wise based on the unmet need for modern spacing methods) were trained on alternative training methodology for IUCD services using pelvic models. These master trainers (NIHFW faculty, SIHFW faculty, state program managers and service providers) would further train district level trainers for training TABLE 1: SUMMARY OF COURSES IN COLLABORATION WITH NIHFW S. No. Course/Conference Target audience Duration Number of participants 1 PPP Conference 2005 PPP implementers, policy makers 1 day 2 Course on Decentralization of Heath Program managers and implementers at the 5 days 49 Systems, 2007 state and district levels 3 Course on PPPs in the Health Sector, Agra, UP Course on PPPs in the Health Sector, Lucknow, UP Course on PPPs in the Health Sector, Nainital, Uttarakhand Course on PPPs in the Health Sector, Ajmer, Rajasthan Course on PPPs in the Health Sector, Uttarakhand Alternative Training Methodology for IUCD Source: Workshop Process Documents, ITAP Senior and middle level executives, and technocrats from state/district/below district levels Senior and middle level executives, and technocrats from state/district/below district levels Senior and middle level executives, and technocrats from state/district/below district levels Senior and middle level executives, and technocrats from state/district/below district levels Senior and middle level executives, and technocrats from state/district/below district levels Representatives from Ministry of Health and Family Welfare, program managers and service providers from 12 states, resource persons from NIHFW and SIHFW 5 days 47 5 days 44 5 days 27 5 days 17 5 days 22 6 days 56 6 The concept of EAG was initiated especially to ensure population stabilization and intersectoral convergence. EAG states are categorized as those with high fertility rates and weak socio-demographic indicators (NRHM, 2005) Collaborations and Support at the National Level 7

22 the service providers (medical officers, staff nurses, lady health visitors (LHVs) and auxiliary nurse mid-wives (ANMs) of the identified pilot districts. The representatives from the Ministry who underwent the training of trainers (ToT) course provided monitoring and supervision support to the activity. The ToT was conducted by NIHFW in June 2007 in three batches. The IFPS Project with support from technical experts, identified from the field developed the reference manual, trainers notebook and participant handbook, and quality checklists. The master trainers went back to successfully train the service providers from respective districts, throughout the country. The Ministry representatives have been monitoring the program in different states. The materials developed by the IFPS Project have been effectively used for conducting the training at the state level. Course on decentralization of health systems Decentralized planning has been one of the core approaches introduced as part of the IFPS Project s early efforts in UP. In 1995, the IFPS Project identified decentralization as a priority for the state in order to effectively implement all health programs. Decentralized health planning could meet specific needs of local constituencies more effectively, could inform efficient decision making processes at the local level, encourage efficient utilization of local resources and increase accountability of the health program to the local community. At the same time, major changes in the district government created a favorable environment for decentralization. In 1997, the IFPS Project introduced and started a discussion on creation of District Action Plans (DAPs). A pilot was carried out in the Rampur District, based on which the model was scaled up in a phased manner to cover 33 districts in UP. The success of the DAP approach saw the GoI, adapting and implementing it across the country through the NRHM. Decentralization forms one of the key pillars of the NRHM implementation processes. Based on the experiences from UP, the IFPS Project in collaboration with NIHFW and the International Health Systems Group, Harvard School of Public Health designed a course to share Indian and international experiences in designing and implementing decentralized plans. Acclaimed resource persons from the Harvard School of Public Health conducted the course and used course modules from the World Bank Flagship Course on Health Sector Reform and Sustainable Financing, as well as created study materials (case studies) specific to the context of the course. The course presented ways of designing and implementing decentralization to best improve a health system. The course content included analytical approaches to decentralization, learning practical design and implementation issues, need to adjust and change decentralized systems and draw upon lessons from other countries experiences. The course provided an opportunity for the resource persons from NIHFW to build their capacities to be able to develop training material and to organize and conduct such courses. Collaborations on research and analyses The IFPS Project collaborated with NIHFW to conduct several studies, one of which is the cost effectiveness study of the Sambhav Voucher Scheme in Uttarakhand. The Sambhav Voucher Scheme is one of the PPP models designed and implemented by the IFPS Project in the three focus states of UP, Uttarakhand and Jharkhand. A key area of interest regarding voucher schemes is their cost-effectiveness, especially given the concerns about administrative costs for managing the programs. NIHFW has had health economics expertise but never conducted cost effectiveness studies. Cost effectiveness studies have garnered interest in recent times, and are considered important to inform policy makers of optimal utilization of resources. Several PPP models are being implemented in different states in India, but their feasibility to scale up, based on cost effectiveness analyses results, has largely remained unattended. To address these gaps, NIHFW decided to enhance its capacities to conduct such studies, in terms of the study design, preparation of data collection tools, data analysis and interpretation, and dissemination of information to policy makers and program managers. With these objectives, the cost effectiveness analysis of the Sambhav Voucher Scheme in two blocks of Hardwar district was conducted. The analysis provides insights into various dimensions that can inform policy and future strategies of the program. Expert consultants from NIHFW prepared the tools and methodology for the study with program inputs from the IFPS 8 Capacity Building of Institutions in the Health Sector