Training report GO NGO collaboration in India for delivering primary health care to the poor

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Training on
Practices of GO-NGO Collaboration for Health Service to the Poor
Program Completion Report
International Institute of Health Management Research, New Delhi had organized a training
program on “Practices of GO-NGO collaboration for Health Service to the Poor” for Urban
Primary Health Care Services Delivery Project from 3 to 9 December, 2015 in India. The
following participants were participated in the training:
(1) Md. Abu Bakr Siddique, Project Director, Urban Primary Health Care Services
Delivery Project
(2) Md. Abdul Wadud, Chief Executive Officer, Comilla City Corporation
(3) Dr. Sanjida Islam, Program Officer, PIU, Dhaka South City Corporation
(4) Md. Wazed Ali Pramanik, Monitoring and Quality Assurance Officer, PIU,
Sirajgonj Municipality
(5) Md. Shagedul Hoque Masum, Project Manager, DSCC PA5 PSTC
(6) Mahfida Dina Rubiya, Project Manager, DNCC PA5 DAM
(7) Md. Maniruzzaman Moral, Project Manager, RCC PA2 PSTC
(8) Md. Abdur Razzaque, Project Manager, KCC PA1 KMSS
2. Objectives of the course
The health care services in the developing countries are passing through a transitional stage.
An urgent need for changes in organization of health care structure and system is being felt.
Within the existing system there is a gap between rich and the poor, urban and rural and
availability of primary, secondary and tertiary care services. The gaps in services have been
widening for the poor people living in rural areas and urban slums. Among others, effective
mechanism to deliver services through Non-Government Organizations with the support of
the government has been becoming popular day by day. In this context, the objectives of the
training were: (1) To understand, observe and compare, the strengthens and weaknesses of
GO and NGOs dealing with health service delivery (2) To familiarized the participants with
key issues in health practices in developing countries (3) To gain knowledge from existing
practices in India to optimize the functioning of GO and NGOs (4) To develop effective
collaboration mechanism between GO and NGOs to deliver quality Primary Healthcare
services. The program was a combination of classroom lectures and field visits.

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3. Class room lectures
(i) India General Facts: India is the 7th
largest country of the world by area and 2nd
largest
country with 1.21 billion people (Census 2011). The country is a union of 29 states and 7
union territories. For administrative purpose, the states and union territories are divided into
districts. Each district is further divided into sub-districts, which are commonly known as
Blocks. The lowest primary administrative units of administration are the villages in rural
areas and towns in urban areas.
(ii) Health System in India: Health system in India has three main links: central, state and
local. The central government’s responsibility consists mainly of policy making, planning,
guiding, assisting, evaluating and coordinating the work of state health ministries. At centre,
there are Ministry of Health and Family Welfare, Directorate General of Health Services, and
Central Council of Health and Family Welfare. States are largely independent in matter
relating to the delivery of health care to the people. Each state has developed its own system
of health care delivery. The country spends around 1.2% of the annual budget for health care.
85% from state government and 15% from central government are the source of government's
health expenditure. Private sector is dominating clinical services by holding 93% of hospitals,
64% of beds, 80% of doctors, 80% of outpatients, 57% of inpatient. As per World Health
Organization, 75% health expenditure comes from out of pocket. Overall health status in
India is on improving trends. The total fertility rate has declined from 3.2 in 2000 to 2.4 in
2012, MMR is 178(2011), under five child mortality rate is 52 (2012). There are four types of
government health care facilities at field level. These are:
(a) Sub-center:- Sub-centers are located in village level. One sub-center caters to the health
care needs of 5,000 populations in general and 3,000 populations in hilly, tribal and backward
areas. Services provided by a sub-center are: antenatal, natal, postnatal, family planning and
counseling, treatment of common illnesses like respiratory tract infections, diarrhea, fever,
worm infestation, prevention of malnutrition, implementation of various national health
programs. Each sub-center has 1 female health worker (Auxiliary nurse midwife), 1 male
health worker (Multipurpose worker) and Voluntary worker to help the Auxiliary nurse
midwife. 1 Female Health Assistant (Lady Health Visitor) and 1 Male Health Assistant at the
PHC level are given the supervision of 6 sub-centers. The central government gives salary to
Indian Society : Many Strata
YSR (Aug
2013)
100 Million
Rich and Super Rich (RSR)
200 Million
Middle and Lowe Middle
Class (MLMC)
200 Million
Upper Middle Class (UMC)
700 Million
BULKY BASE (BB) –
Poorly Skilled
Struggling, Hard
Working

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the Lady Health Visitor and the Auxiliary Nurse Midwife in addition to contingency fund,
drug and equipment. The state government gives salary to the multipurpose worker. The
voluntary worker is paid from the contingency fund of the Auxiliary Nurse Midwife.
(b) Primary Health Center (PHC): Primary Health Centers are also located at village level
upper to sub-centers. A PHCC covers around 50,000 populations. Each PHC has 1 Medical
Officer, 1 Pharmacist, 1 Nurse mid-wife, 1 health worker, 1 Block Extension Educator, 1
female Health Assistant, 1 UDC, 1 LDC, 1 Lab technician, 1 driver and 4 Class IV Staff. It is
equipped with a jeep and necessary facilities to carry out small surgeries. The PHCs are
established and maintained by the State Governments. It has 4 - 6 beds for patients. The
activities of Primary Health Centers involve curative, preventive, primitive and family
welfare services.
(c) Community Health Center (CHC): Community Health Centers are located at Block level
to cover 80,000-120,000 population. CHC serves as a First Referral Unit for cases from
Primary Health Centers. It also serves as Block level public health administrative unit.
Generally each CHC is a 30 bedded hospital provides 24 hours normal delivery and C-
section. It also provides all essential services which include routine and emergency care in
surgery, medicine, obstetrics and gynaecology, pediatrics, dental and ayush in addition to all
the National Health Programs. Each CHC has 4 specialist physicians namely, Surgery,
Medicine, Gynecology and Pediatrics. It is mandatory for every CHC to have functional
“Rogi Kalyan Samiti” (Patients’ Welfare Society) to ensure accountability.
(d) District Health Center: District Health Center is a hospital at the secondary referral level.
Its objective is to provide comprehensive secondary health care services to the people in the
district at an acceptable level of quality and being responsive and sensitive to the needs of
people and referring centers. As the population of a district is variable, the bed strength also
varies from 75 to 500 beds depending on the size, terrain and population of the district.
District Hospital provides all basic specialty services. District Hospital is also responsible for
epidemic and disaster management. In addition, it provides skill based trainings for different
levels of health care workers.
(iii) Urban Health Care Delivery System in India: In urban India the health system is
highly diverse, ranging from private health care services to public health care to traditional
healers. Secondary and tertiary care is provided by a multiplicity of agencies viz. the medical
college hospitals, voluntary and private hospitals. The health infrastructure in the public
sector includes State Governments Primary Health Care centers established on the rural PHC
pattern, industrial hospitals, dispensaries and the Urban Health and Family Welfare Centers
(UHFWCs) run by the city municipal corporations. All these except the latter provide
essentially curative services and do not have outreach services for slum populations.
(iv) Health Policy Initiatives in India: India health system follows certain policy and
guidelines. Some of these are: National Health Mission, Indian Public Health Standards
(IPHS), Swachh Bharat Abhiyan (Clean India initiative), Kayakalp (clean hospital initiative

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award for Public Health Facilities), ASHA (Accredited Social Health Activits) initiative, free
ambulance service by calling 108, National Adolescent Health Strategy, Janani Suraksha
Yojana( safe motherhood intervention), Model Health Districts program.
(v) National Health Mission: The government of India launched National Rural Health
Mission (NRHM) in April 2005 to address the health needs of underserved rural areas.
Subsequently, National Health Mission(NHM) was launched on 1st
May, 2013 with two
submissions NRHM & NUHM, with vision “ Attainment of Universal Access to Equitable,
Affordable and Quality Health Care Services, accountable and responsive to people’s need,
with effective inter-sectoral convergent action to address the wider social determinants of
health” and to cater urban population.
(vi) National Urban Health Mission : The government of India has launched the National
Urban Health Mission (NHUM) vide a Resolution dated 15 May 2013, as a sub-mission
under National Health Mission for providing quality primary health care services to the urban
population, especially the urban poor. As per resolution, the mission is to be launched in all
cities/towns with a population of more than 50,000, all district headquarters and state capitals.
Town with a population below 50,000 will be covered under the National Rural Health
Mission. National Urban Health Mission (NUHM) aims to improve the health status of the
urban population, particularly the slum dwellers and other vulnerable sections by facilitating
equitable access to quality health care with the active involvement of the Urban Local
Bodies.
Safe Motherhood Intervention

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(vii) Association of Social Health Activists (ASHA): Accredited Social Health Activist
(ASHA) is an imitative to deliver health service in India through social workers. At village
level, there is one ASHA Volunteer for 1,000 population. For 20 villages, there is one ASHA
Facilitator. At block level, there is one Block Coordinator. At district level, there is a District
Coordinator. ASHA workers have been playing a pivotal role in the implementation
of National Rural Health Mission and bringing down the infant mortality rate by ensuring
institutional deliveries, ensuring vaccination of children, providing all services of family
planning and reducing anaemia among women and children. All over the country 8.9 lakh
ASHA workers distribute contraceptives to eligible couple at the door step. ASHA workers
also provide counseling to newly married couples to ensure spacing of 2 years after marriage
and to have spacing of 3 years after the birth of 1st child. ASHA volunteer is being paid
following incentives under the scheme: (1) Rs. 500/- for ensuring spacing of 2 years after
marriage (2) Rs. 500/- for ensuring spacing of 3 years after the birth of 1st child (3) Rs.
1000/- in case the couple opts for a permanent limiting method up to 2 children only.
(viii) RMNH+A Approach: Reproductive, Maternal, Newborn plus Adolescent Health
(RMNCH+A) approach has been launched in 2013. It address the major causes of mortality
among women and children as well as the delays in accessing and utilizing health care
services. This approach brings focus on adolescents as a critical life stage and linkages
between child survival, maternal health and family planning interventions. The approach
aims to strengthen the referral linkages between community and facility based health
services. It also lays emphasis on health systems strengthening as the foundation on which
technical interventions must be overlaid for effective outcomes.
(ix) Community Health Insurance Schemes: In India community health insurance has
emerged as a possible means of (i) improving access to health care among the poor and (ii)
protecting the poor from indebtedness and impoverishment resulting from medical
expenditure. Community based schemes are based on principles: Community Cooperation,
Local Self Reliance and Pre-Payment. In Karnataka state, Yeshasvini Cooperative Farmers
Health Care Scheme (Yeshasvini Scheme) was introduced in 2003 by the state government
with a vision to assure quality healthcare services for the farmers. At present, Yeshasvini is
one of the largest self funded healthcare schemes in the country.
(x) Inter-sectoral Cordination: Inter-sectoral coordination for achieving health goals has
been accepted as one of the guiding principles of the health strategy that was adopted at the
international conference on primary health care (Alma-Ata, 1978). There are many
governmental departments and agencies working for people whose activities are closely
linked with health. Most of the times, these programs pursue the achievement of their specific
objectives in a vertical manner losing sight of the ultimate goal of primary health care. It is
to ensure unity of purpose and direction and to encourage team work to deliver primary
health care at various levels.
(xi) Role of NGOs: India has largest number of NGOs in the world with around 2 million
registered NGOs under the society act. About 10,000 NGOs are funded by government for

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different activities, around 4000 of these are health related. NGOs are divided into two
categories, field NGOs and service NGOs. Field NGOs carry out activities like training and
capacity building, community monitoring, advocacy, community mobilization, planning etc.
Service NGOs provide service delivery. As per government policy, up to 5% of the
government health allocation is utilized through NGOs. Ministry of Health and Family
Welfare through its NGO Division providing grant-in-aid to National level NGOs. NGOs are
selected for 3 years if proposal accepted. NGO budget proposal limit: salary 35%,
contingency 10%, house rent, capacity building TA DA 25%. Government releases 15% fund
in advance, 2nd
installment 40%, 3rd
installment 40% and last 5% after received audited
statement and PCR. Financial parameter for selection of NGO are annual turnover of at least
50 lakh for the national or regional level, Rs 25 lakh for State Level and Rs10 lakh for district
level projects. NGOs should have appropriate infrastructure, strong community outreach
networks, stable governance structures, transparent financial systems and flexible
administrative norms. Factors of continuous of funding are : (a) Project performance record
(b) Deliverable done (c) Third party evaluation (d) Efficient networking (e) Past track record
(f) Efficient finance management (g) Product specialization (h) Innovation in management.
(xii) Framing MOU: A memorandum of understanding (MOU) is a formal agreement
between two or more parties. Companies and organizations can use MOUs to establish
official partnerships. MOUs are not legally binding, but they carry a degree of seriousness
and mutual respect stronger than a gentlemen’s agreement. Often, MOUs are the first steps
towards a legal contract. A standard MOU should have following sections: introduction,
purpose, scope, definitions, policy, user procedure requirements, maintenance, oversight,
responsibility of standard operational procedure (SOP), procedure to update MOU.
(xiii) Health for the poor: In India, around 38% people live below poverty line. Government
issues Below Poverty Line (BPL) card for the poor based on their income. Both urban and
rural, below 6000 Rs monthly family income is entitled to get BPL card. Community health
insurance has been introduced in some areas such as Karnataka. Besides government, NGOs
are playing important roles to deliver health services to the poor.
(xiv) Free Voucher Scheme Project: Free healthcare vouchers to approximate 600,000
Below Poverty Line (BPL) families across 368 urban slums of Kanpur (Uttar Pradesh)
enabling to avail free reproductive healthcare services at accredited private providers.
Voucher distribution was done with support from the local NGOs and community volunteers.
The main objective of the project was to improve accessibility of quality RCH services
through engagement and accreditation of private health facilities. Under the project, 17
private facilities were accredited in the target geography based on their location and quality
standards. Under this scheme, had been provided 5846 safe deliveries, 8549 ANCs, 1798
family planning services and 3997 STI/RTI services, 2552 PNC services. In the project area,
institutional delivery had been increased from 18% to 70% within three years of project
period and Contraceptive Prevalence Rate increased from 39.8% to 46.8%. Certain
innovations from the project have been adopted by NRHM for the entire state.

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(xv) PPP for health: Public-Private Partnership for health is an approach to addressing
public health problems through the combined efforts of public, private and development
organizations. This is a win-win situation for all where public sector organizations may
achieve their objectives faster and with smaller investments, private sector organizations are
able to expand their markets, develop new marketing techniques, and contribute to the
communities in which they do business and development organizations achieve their strategic
objectives in collaboration with others. Objectives of PPP are: (a) To ensure government
services are delivered in an economical, effective and efficient manner (b) To create
opportunities for private sector growth and to contribute to the overall economic development
of the District/State/Country through the stimulation of competitiveness and initiative and (c)
To ensure the best interests of the public, the private sector and the community are served
through an appropriate allocation of risks and returns between partners.
Key stakeholders of PPP
Some PPP Model in India:
(a) Uttaranchal Mobile Health and Research Clinic provides clinical & radio diagnostics
through health camps, lab tests free to all BPL cardholders.
(b) Primary Health Centres in Gumballi and Sugganhalli, Karnataka contracted out to
Karuna Trust in 1996 to serve the tribal community in hilly areas. 90% cost borne by
Government and 10% by the trust. Karuna Trust has full responsibility – Provision of
all personnel in the Primary Health Centres and the Sub-centres within jurisdiction,
maintenance of assets and addition if required, ensuring stocks and supplying them free
of cost. No patient is charged.
(c) Man Singh Hospital, Jaipur has contracted out the installation, operation and
maintenance of CT scan and MRI services to a private agency. Agency is paid monthly
rent by the hospital. Free services to 20% of poor patients and low cost to others.
(d) Karnataka Integrated Tele Medicine and Tele Health (KITTH) project - Govt of
Karnataka, Narayana Hrudayalaya and ISRO- Functions in the CCUs of selected district
hospitals which are linked with Narayana Hrudayalaya Hospital. Each CCU is

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connected to the main hospital to facilitate management. Tele medicine tremendously
improves access to speciality care.
(e) Uttaranchal Mobile Hospital : Three way partnership between Technology Information,
Forecasting and Assessment Council (TIFAC), Govt of Uttaranchal and the Birla
Institue of Scientific Research (BISR). Provision of health care and diagnostic facilities
to rural population at their door step in difficult hilly terrain. TIFAC and State
Government share the funds sanctioned to BISR on equal basis.
(f) Aravind Eye Hospitals Chennai, a private trust contributes to the State by performing
high volume, a staggering 42% of total surgeries in the State relieving its burden.
(xvi) CSR for Health Care: In 2013 government of India had amended section 135 of the
Company Act and made provision that every company having net worth of rupees five
thousand crores or more or turnover of rupees one thousand crores or a net profit of rupees
five crores or more during any financial year shall constitute a Corporate Social
Responsibility Committee of the Board consisting of three or more directors. The Board shall
ensure that the company spends, in every financial year, at least 2% of average net profit of
the company made during the three immediately preceding financial years, in pursuance of its
Corporate Social Responsibility policy. Number of activities can be done in CSR including
health care.
4. Field Visits
(i) ASHA Hospital: Located at Vikash Puri, New Delhi, ASHS is a private clinic provides
maternal check up and family planning services at subsidized rate. Field workers of the local
branch of NGO Population Services International (PSI) refer clients to this clinic.
(ii) Population Services International (PSI): Population Services International (PSI)
provides door to door Inter Personal Counseling (IPC) on family planning. Each field worker
covers 1800-2000 households in a year and keeps records of the clients. Coordinator level

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staff holds group discussion. Field workers also refer clients to ASHA clinic for family
planning and reproductive services.
(iii) Visit to Jhpiego: Jhpiego is an international NGO and an appellate of Johns Hopkins
University. In collaboration with the Ministry of Health and Family Welfare, the NGO
provides support to improve quality of delivery care, new born care and family planning
activities. Some of the activities are :
 Technical assistance to introduce, establish and postpartum intrauterine contraceptive
device (PPIUCD) services into existing postpartum family planning (PPFP) services in
16 states
 Developed a comprehensive, multi-stakeholder strategy in Bihar State to implement a
statewide postpartum family planning program through public and private sector
facilities
 Implementing a three-year project to test the integration of a World Health
Organization Safe Childbirth Checklist into targeted health facilities in Rajasthan.
 In the states of Madhya Pradesh, Orissa, Rajasthan and Bihar, Jhpiego is working to
improve the quality of pre-service education for nursing and midwifery cadres
 Jhpiego is forming a Technical Support Unit at the request of the MOHFW to provide
technical assistance to their Family Planning Division.
 Jhpiego is working in Uttar Pradesh and Jharkhand to leverage the large network of
private sector providers to improve access to high-quality, evidence-based antenatal,
intrapartum and immediate postpartum care and family planning services to mothers.
 Jhpiego is working in Chhattisgarh and Odisha to increase contraceptive choice in
public sector, sub-district health facilities by establishing postpartum, post abortion,
interval IUCD and family planning counseling
(iv) National Health Systems Resource Centre: National Health System Resource Center
(NHSRC) is an autonomous body under Ministry of Health/ It is a WHO collaborating center
works for priority medical devices and health technology policy. The organization is divided
into ten divisions. It maintains a National Innovation Portal for public health. It suggests
specification for medical equipment to be procured for government hospitals.

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(v) Tuberculosis Association of India: The association had established in 1939. Director-
General of Health Services is the chairman of the association. The association provides 3
months DOTS course for the DOTS workers. Advocacy, Communication and Social
Mobilization (ACSM) are the strategy of the association. Every year 2nd
October on the
Gandhi Jayanhti, the association launches its TB Seal Campaign to raise fund.
5. Conclusion
India is a country with huge population. Public sector expenditure, human resource and
infrastructure network, etc are not enough to cater essential health care for all. As a result, the
government of India is encouraging alternative sources for service delivery. The government
spends funds through NGOs to serve underserved areas, involves community organizations
for health insurance and free voucher scheme. The state governments are outsourcing
services through public private partnership, engaging local level volunteers to ensure door
step service, make partnership with private organizations to provide technical supports to
public sector facilities, insist private companies to contribute under CSR for health care.
Following lessons gained from the training may be implemented in Bangladesh.
(1) Under National Urban Health Mission, government of India has taken separate initiative
to address primary health care for the urban people living in the cities having more than
50,000 populations. Similar initiative is necessary for Bangladesh.
(2) Present NGO contracting system of UPHCSDP has some weaknesses. Among others,
price based competition and change of NGO for a particular area is not suitable for
clients’ interest. Some lesson of NGO selection criteria and fund continuation system of
India may be considered.
(3) System of final 5% fund release to NGOs after audit and PCR in India may be
implemented in UPHCSDP.

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(4) India’s health expenditure sharing among central and state government at 15: 85 ratio
which can be implemented in future where LGD may share 85% and a participating city
corporation or municipality may share 15%.
(5) City Corporation and municipality may raise fund for health delivery from industries
and big commercial enterprises under CSR arrangement by amending present act.
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