Details for Reform Option "Women-centred health project, Mumbai, Maharashtra"
The Municipal Corporation of Greater Mumbai (MCGM) (also known as Brihan Mumbai Municipal Corporation i.e. BMC) is the largest health care provider in the public sector in the Mumbai metropolis. Approximately three million women, particularly the poorest ones use the municipal health care services.
The Women Centred Health Project (WCHP) was initiated in 1996 by BMC in collaboration with SAHAJ, an NGO and Liverpool School of Tropical Medicine, UK. The aim was to improve the quality of services provided by public health department of the MCGM.
A study on the prevalence of Pelvic Inflammatory Disease (PID) in slum women of Mumbai showed that women who attended the dispensaries for conditions like infertility, pelvic inflammation diseases and for sterilisation operation had special problems.
Often, they did not have access to adequate information. Most municipal health care facilities lacked counselling services. Availability of limited gynaecological services at the primary level health care facilities meant that women had to avail speciality services at the secondary or tertiary hospitals which were costly in terms of time and money spent on accessing these services. Women also expressed a need for doctors to speak to their spouses as they had little decision making power.
Initially, process and baseline studies were carried out to understand the health infrastructure and services provided.
The baseline study brought out the following:
(i) Men’s perception of their responsibility regarding RH is largely limited to financially supporting women in treating their reproductive problems.
(ii) Men had unmet information needs regarding reproductive and sexual health of both men and women and they preferred male health workers to conduct health information sessions.
(iii) Limited counselling, information and education, on diagnosis, advantages and disadvantages of treatment and other interventions, social aspects directly related to health problems.
(iv) The need to sensitise providers on their behaviour, and clients’ perceptions.
(v)The need to implement clinical and administrative protocols at all levels of the health care delivery system.
In light of the findings of the surveys, the following steps were taken:
(i) Gynaecology Outpatient Clinics (GOCs) started at 8 health posts.
(ii) A counselling centre was started at the GOC at a secondary hospital in January 2000.
(iii) Development of gender sensitive interactive IEC material on Reproductive Tract Infections (RTIs), Medical Termination of Pregnancy (MTP) and Ante-Natal Care (ANC).
(iv) Developing a Patients’ Charter including the Rights of Patients.
(v) Development of training manuals for sustaining the capacity building component beyond the project period.
The introduction of gynaecological OPDs at the health post and dispensary levels has helped services to improve and also brought women closer to quality health care services in a sensitive and private environment.
This has helped them prioritise their health needs and seek treatment for problems which they would otherwise ignore. This was reflected in the fact that the number of women visiting the dispensaries for treatment increased three times in just a year.
Health care providers feel that the project’s efforts at strengthening and streamlining the referral system will reduce the load at tertiary and secondary hospitals and help patients with referrals to receive priority treatment. The referral system is viewed as a tremendous achievement within the MCGM.
The WCHP cost totalled to approximately INR. 8,000,000 spread over 7 years with a significant contribution from the MCGM.
Seventeen health posts and 14 dispensaries, one peripheral hospital in two wards of the MCGM in Mumbai
1996 – 2003
Between five to 7 years since it is process intensive.
Incentives: The Quality Assurance approach ensured ownership of the hospital by the staff and encouraged teamwork with a goal of client satisfaction.
Gender inclusive: Men were involved in the process.
Broadening the appeal increases the caseload: services need to be planned so that the quality of care can be sustained.
Time constraints: such process oriented approaches take time which is not always available to government officers and health care providers.
Work overload: National health programmes such as immunisation, polio, and TB can become a constraint, leaving health workers less time to concentrate on this project.
Needs education: Importance of gender sensitisation in RH provision may not be acknowledged by all health care providers and administrators thus according low priority to the programme and affecting the pace of progress of interventions.
Additional workload perception: Health care providers who have been ‘ordered’ to participate may resent it and oppose the pilot interventions as ‘additional workload’.
Peer pressures: Health care providers participating in the pilot phase may be influenced by negative peer pressure and may not express ownership of the interventions.
-- Willingness of the public sector partner for exploring newer strategies for improvement of quality of care.
-- Existing infrastructure, administrative pathways, and human resources.
-- Training for change to all cadres of health care providers and administrators.
-- Provision of physical resources that could not be mobilised from the PHD of MCGM.
-- Coordination of monitoring and supervision of services provided through the gynaecology clinics and the counselling centre, including honoraria for the supervisors.
Who needs to be consulted
Highest authority for the public sector partner. For example, Municipal Commissioner for MCGM. Patients, their relatives, healthcare facilities, healthcare staff.
Ownership of the interventions by the administrators concerned, and initiative by them for ensuring sustainability (through support in terms of resources and monitoring), are some of the crucial factors. Mass production of gender sensitive IEC material produced by WCHP is being taken over by the IEC Cell of BMC.
The work on Referral Systems initiated by WCHP has been taken over by another partnership initiative, SNEHA and referral protocols are being developed and refined.
The Counselling Centre within the gynaecology OPD in VN Desai Hospital continues to provide services and is in the process of being taken over by the hospital administration.
However, inability of the MCGM to recruit personnel to fill the vacant staff positions is likely to result in the death of the interventions like the primary level Gynaecology Clinics.
In the later phases, the project focussed its efforts on ensuring that the MCGM qualified for the second phase of the National Programme on RCH through which the interventions initiated by the project could be mainstreamed and sustained.
Chances of Replication
The intervention is replicable in an urban setting with adequate training and protocol formulation. MCGM has planned to expand it to other wards.
Training the staff in communication skills and sensitivity for women having gynaecological and other health problems can result in increase in the utilisation of the services. However, it requires the involvement of the staff, which may take some time to show results.
Sara Joseph, Researcher, ECTA, New Delhi. September 2004.