1. Medical Officers authorised to arrange maintenance and repairs on Primary Health Centres ...

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1. Medical Officers authorised to arrange
maintenance and repairs on Primary
Health Centres, Gujarat

Subject
Area="Infrastructure Objective="Maintenance of health facilities."
and Equipment."
Details for Reform Option "Medical Officers authorised to arrange maintenance
and repairs on Primary Health Centres, Gujarat"
Summary Background: Minor civil works and repairs (including
replacement of window panes and repair of taps) at
Primary Health Centres (PHCs) and Community Health
Centres (CHCs) were being held up because the power to
authorise such work and the funds are held at state, not
district, level - with the Roads and Buildings (R&B)
Department. The R&B Department is more interested in
major, not minor, works, leaving PHC and CHC buildings
in a dilapidated state.
Action: Under the European Commission's Sector
Investment Programme (SIP), Medical Officers (MOs) at
PHCs and Medical Superintendents at CHCs were given
the authority to commission and select contractors and
carry out up to INR 25,000 per year of minor repairs (each
work costing no more than INR10,000 ) on buildings. This
was initially piloted in two districts and then rolled out to
all 25 districts in the State, using funds provided by the
SIP, the World Bank-supported Reproductive Child
Healthcare (RCH) programme and UNFPA's Integrated
Population and Development Programme. Funds are
released to the MO by the District RCH Societies who were
given the power to appoint local agencies to carry out the
work, to authorise works above INR 10,000 with an upper
ceiling of INR 10 lakh. A Government Order (GO) to this
effect was obtained on the recommendation of the
Narmada and Rajkot District Agencies (DAs) on 30
September 2000.
Results: There has been a quick and appreciable
improvement in facilities as well as an efficient utilisation
of the funds available. The State Government is now
considering a proposal to to sustain this initiative by using
the Government funds allocated to the R&B department
for repairs and maintenance of health facilities.
Cost No added cost implication.
Place Gujarat. Initially in Rajkot district from late 2000 and
Narmada district from July 2002. Extended in January
2005 to cover all 25 districts.
Time Frame Three months but would vary depending on the size of the
district.
Advantages Speed: Minor works are undertaken quickly.
Quality: Improved service delivery.
Morale: Boosts staff morale and gives district agencies and
MOs a sense of ownership.
Challanges Corruption: Possible abuse of funds - needs careful
auditing.
Clarity: Proper guidelines were not provided to MOs so not
all properly understood the procedures they had to follow.
In addition some District RCH societies were not confident
enough to release funds to the MOs.
Funds flow: Held up initially because there was no bank
account for the District RCH society to pay the money
into. This has now been rectified.
Prerequisites GO to empower MOs to take up civil works and identify
contractors. Resolution of the DA to implement the GO.
Training of PHC MOs to select cost-effective and efficient
contractors to carry out necessary repairs. Guidelines for
MOs and DAs.
Who needs to be State Government. District Agency.
consulted
Risks None Identified.
Sustainability Has functioned for the last six years and it is now planned
to extend the decentralisation initiative to Government
funds which will make it sustainable in the long term.
Chances of Replication Judged to be good.
Comments The Additional Director (Family Welfare) has also been
given financial powers of up to INR 5, 00,000 per activity
per annum and administrative powers to appoint
contractual staff to carry out building works. They can
also appoint staff on deputation for project activities
bringing more flexibility into the system.
Contact
Submitted By Dr Uma Vyas, State Facilitator, Gujarat, for Health and
Family Welfare Sector Programme in India, supported by
the European Commission. July 2002.
Status Active
Reference Files
MO describes the work MO describes the work
carried out at the carried out at the PHC
PHC.mpg
PHC Garudeshwar,
Narmada District
September 2001.jpg

Decentralised
administrative and
financial powers enabled a
painter to be employed.jpg

PHC Medical Officer
showing the wall and
windows at Samarpada
Sub-Centre.jpg

PROD Gujarat delegated
powers.doc

Presentation AJ Powerpoint Presentation on
Gujarat.ppt Decentralisation, State

Government of Gujarat,
January 2006.
2. Medical Officers empowered to
authorise minor maintenance to
Community Health Centres and Block
Primary Health Centres, Orissa

Subject
Area="Infrastructure Objective="Maintenance of health facilities."
and Equipment."
Details for Reform Option "Medical Officers empowered to authorise minor
maintenance to Community Health Centres and Block Primary Health
Centres, Orissa"
Summary Background: Lack of minor and routine maintenance of
health centres because the work had to be done by the
engineering section of the Rural Development Department
(RDD) – often situated many miles away. The RDD was
unable to cope with both the distance and the numbers
(4000 plus) of health facilities it had to maintain in the
state.
Action: The Medical Officer (MO) in charge was given INR
10,000 per year to carry out maintenance and minor
repairs of Community Health Centre (CHC) and Primary
Health Centre (PHC) buildings. Basic accounting and
book keeping training was provided to keep track of
spending. After a review of the initial project, MOs were
also given training on how to efficiently use these funds
and prioritise maintenance needs. The Department of
Health and Family Welfare, Government of Orissa,
introduced this as a minor maintenance scheme as part
of its maintenance policy reform strategy in 1997-98.
Cost No cost implications.
Place One hundred CHCs and Block PHCs in Orissa since
financial year 1997/98, planned to increase by 100 each
year.
Time Frame Two years.
Advantages Speed: Pressing repairs can be carried out without too
much delay.
Visibility: Noticeable improvement in the quality of
facilities.
Challanges Increased workload: Increased burden of responsibility on
MOs.
Accounting: Necessity to account for funds correctly and
need for MOs to be properly trained in accounting.
Corruption: Possible misuse of funds.

Prerequisites Training of MOs in general management. Prompt passing
of bills for payment. Guidelines for use of funds and
accounting. Ongoing management support at district
level.

Who needs to be District Health & Family Welfare Agencies, State
consulted Government, heads of facilities, Rural Development
Department, CHC / PHC MOs.

Risks None identified.
Sustainability Has been extended to cover 600 institutions in the state
(August 2004). Similar scheme being undertaken in
Gujarat (See PROD link).

Chances of Has been extended to cover 600 institutions in the state
Replication (August 2004). Similar scheme being undertaken in
Gujarat (See PROD link).

Comments None.
Contact
Submitted By Dr. Matthew Jowett, Former Programme Adviser,
European Commission Techincal Assistance Office, New
Delhi. July 2002.

Status Active
Reference Files
Reference Links
3.Maintenance of First Referral Units and
Civil Hospitals, Assam

Subject
Area="Infrastructure Objective="Maintenance of health facilities."
and Equipment."
Details for Reform Option "Maintenance of First Referral Units and Civil
Hospitals, Assam"
Summary Background: Ten years of under funding at the Public
Works Department (PWD) in Assam had led to lack of
repairs and poor maintenance of hospital buildings. In
order to improve the services in hospitals and to bring
about partial modification in the health department,
Government of Assam decided to set up a hospital
management society for the medical college hospitals,
hospitals attached to teaching institutions under the
directorate of medical education, Assam as well as the
state hospital, district hospitals and sub - divisional
hospitals under the directorate of health services,
Assam.
It was decided that a society be formed in accordance
with the provisions of the Memorandum of Association
(MOA) and the rules and regulations (bye laws) formed
for this purpose. It had to be registered under Society
Registration Act XXI, 1860. The Joint Director of Health
Services in the District and the Sub Divisional Magistrate
(SDM) and Health Officer (HO) of the sub- divisional head
quarter, were responsible for taking necessary steps to
form hospital management society for district hospital
and sub- divisional hospital respectively as per
provisions of the scheme within a period of one month.
Hospital management society was given the power to
exercise autonomy to a large extent, on expenditure to be
incurred from the revenue collected by the hospital in
the form of donations, membership fees, user charges
and government grants.
Action: After such a Government Order was issued, the
responsibility of maintenance of Bhugeswari Phukanani
Civil Hospital (B.P. Civil Hospital), Nagaon and the First
Referral Units (FRUs) were switched to the District
Health and Family Welfare (DH&FW) agency in Nagaon,
which was given the funding for the task. It was also
authorised to approve repairs and renovations and select
the contractor who would carry out the work. It, in turn,
formed hospital management societies at a local level
and gave them the responsibility to carry out the work by
preparing repair and cost estimates and submitting them
to the DH&FW agency for approval.
Results: Initially started as a pilot project, the
programme has sustained itself. Hospital management
societies have been formed in the B.P Civil Hospital and
the 4 FRUs (Jakhalabanda, Hojai, Dhing and Lumding)
in Nagaon District. The PWD and other government
engineers provide technical help for the work. Through
the funds from the government and user charges,
commendable work is being carried out. The monthly
collection from user fees alone in B.P Civil Hospital,
Nagaon ranges between INR 2-3 lakhs. A few examples of
the achievements of developmental works that have been
carried out in B.P. Civil Hospital are: * Repairing and
renovation of blood bank and ultra-sonography machine.
* Repairing and renovation of medical ward. * New
electrification with fans in female medical ward and
blood bank. * Repairing of x-ray machines. * Repairing
and white washing of administrative building, district
medical store, immunization centre and conference hall.*
Repairing and renovation of medical paying cabins and
surgical paying cabins. * Purchase of 100 beds with
accessories. * Purchase of two Maruti Van Ambulance.
Cost Not specified.
Place Nagaon District, Assam
Time Frame Three months. The programme began in 2002 and is
continuing since then.
Advantages Decentralisation: Because financial and administrative
responsibility for maintenance is now at a local level,
work is being carried out more effectively and efficiently.
Improved facility: Improved maintenance and
upgradation of hospital facilites.
Inclusive: Greater integration of community
representatives.
Challanges Cost: Supervision charges have to be paid to the govt
engineers, thus increasing the cost.
Decision Making: The executive committee does not have
a full say in decisions which poses as a problem at times.
Contractual Staff: For cleaning only contractual staff can
be hired not permanent.
Workload: Extra work is imposed on H& FW (doctors)
due to staff shortage.
Prerequisites * Delegation of powers and availability of adequate funds.
* Availability of civil engineering support.
Who needs to be District Health and Family Welfare Agency, Nagaon
consulted
Risks
Sustainability The program is running successfully since 2002. The
activities have been sustainable through community
participation like user charges, donation, from other
sources like District Rural Development Agency (DRDA),
Member of Legislative Assembly (MLAs) funds etc.
Chances of This option has been replicated already in other health
Replication facilities, using outside donations, user charges and
other resources for renovating and building new hospital
buildings in the state. This was done by the local
management committees and not the PWD.
Comments This reform has been a crucial factor in operationalising
FRUs in the State. In conjunction with reforms allowing
the District Health Agency to improve equipment supply
and ensure manpower deployment.
Contact
Submitted By Indrajit Pal, Former Programme Adviser, European
Commission Technical Assistance, New Delhi. July 2002.
Last Updated: July 2006
Status Active
Reference Files
IMGP2099.JPG Maternity ward, Civil Hospital, Nagaon.

IMGP2094.JPG Silent generator bought from user fees,

Civil Hospital, Nagaon.
IMGP2098.JPG Mobile medical vans bought from user

fees, Civil Hospital, Nagaon.
4. Model Out Patient Door, Himachal
Pradesh

Subject
Area="Infrastructure Objective="Maintenance of health facilities."
and Equipment."
Details for Reform Option "Model Out Patient Door, Himachal Pradesh"
Summary Background: It was noticed that utilisation of the services
from Out Patient Door (OPD) was severely affected due the
limitations of existing infrastructure. For example, patient
waiting areas needed to be improved; drainage in few
places was poor leading to collection of water, toilet
facilities needed facelift for the patients. Labour room for
conduction of deliveries at few places were not suitable
located.
Action: To revamp the health facilities, model OPD was
constructed by re structuring the existing OPD under
European Commission Sector Investment Programme. It
meant redesigning existing facility or does minor changes
to make place comfortable and convenient for patients.
While designing the new OPD care was taken to provide
shaded waiting areas to the patients, chairs and couches
for their sitting arrangements and public toilets. Space was
identified for the labour room so that pregnant ladies can
be easily managed at the time of their delivery. Health
department staff in the particular premise was responsible
to identify the ways in which services could be improved for
patients.One health facility was identified from each
constituency on the basis of relatively good patients load
and strategically good location. Government guidelines,
which are situation specific and with emphasis on
decentralized decision-making to revamp the health facility.
Medical Officer of Health is responsible to identify the
needs and submit proposals in agreement with Public Work
Department (PWD).
Results: Service utilization has increased as evident from
number of the patients has increased to 140 new patients
on an average from 50-60 patients. Also it was noticed that
satisfaction among the patients has increased who are
availing the services from the health facilities.
Cost Approximately INR 2 lakh.
Place 68 places across the State.
Time Frame Six months to one year, depending upon the speed of work.
Advantages Face lifting of the dilapidated building: Minor changes in
the existing infrastructure give a facelift to the facility.
Increased utilisation of the health facilities by the
patients: Satisfaction of the patient after availing the
services from the health facilities increases its rate of
utilisation over the period of time.
Challanges Cooperation from PWD: Proposal needs an agreement with
the PWD department. To get them involve in the time
bound revamping process is big challenge for the health
administrator.
Prerequisites State Government approval.
Who needs to be State Government, Public work department.
consulted
Risks
Sustainability Sustainable, though need of a minor repair could arise
from time to time.
Chances of Replicable, in States where infrastructure is in poor
Replication condition to utilise it effectively and where funds are
available to strengthen it.
Comments To create environment for the patients with little but basic
amenities that provide them basic comfort, access to
services with greater responsiveness leads to better patient
satisfaction with over all health care interaction experience.
Contact
Submitted By Dr. Anuradha Davey, Research Consultant, NIMS,
February, 2006.
Status Active
Reference Files
Notification for release of fund- Model OPD.pdf

PHC Amb, Una district1.JPG

PHC Amb, Una district6.JPG

PHC Amb, Una district4.JPG

PHC Amb, Una district27.JPG

Reference Links