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Peer review among district health officers in Maharashtra, India
Int. J. Gynecol. Obstet., 1989,30: 33-36 International Federation of Gynecology and Obstetrics
33
Peer review among District Health Officers in Maharashtra, India V. Srinivasan The World Bank, Washington, DC (USA)
Abstract A management information system in Maharashtra State, India, was used to obtain primary health care performance data for review at monthly meetings of peers, including District Health Officers, Auxiliary Nurse Midwives and Multipurpose Workers. The meetings were conducted in a problem solving, educational atmosphere. The effect of this process was marked improvement in health worker motivation andperformance. Keywords: Medical audit; Primary health care; Management information system. Primary Health Care (PHC) constitutes the single most important international health effort in the 1980s and simultaneously poses the greatest challenge. The main interventions for improved health such as provision of better maternity care, early treatment of diarrhea, complete immunization coverage of infants, health education and family planning are clear. But what appears to elude most large public systems is the capacity to deliver effective technologies/interventions over a whole population through large bureaucracies, and myriad service providers. How 0020-7292/89/$03.50
0 1989 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
do we energize these systems? This paper attempts to describe and analyze some management responses to the question. The capacity of public bureaucracies is basically constrained by the system’s inability (a) to exchange information and to upgrade the skill8 of all members on a continuing basis; (b) to motivate the staff to perform; and (c) to provide, maintain and implement an environment in which corrective policy and action is continuously taken to maximize performance. The central difficulties are thus not so much generated by the medical technology as by the delivery system or institutional development. One successful example in which a conventional information system has been used by management to stimulate excellent PHC performance through a combination of peer review, motivation by ranking and reward, and pursuing corrective action is the case of Maharashtra, one of the constituent States of the Union of India, with a large public health system serving a population of around 62 million. The health delivery system in Maharashtra In rural areas the basic unit, the Primary Health Center (PHC), covers approximately 100,000 people. These PHCs are run by Conference Proceedings
34
Srinivasan
locally elected bodies with a District Health Officer (DHO) supervising the health personnel. One Community Health Volunteer per 1000 population, chosen by the community, is not an employee of the government. While the principal health programs implemented in Maharashtra are (a) Family Planning (FP), (b) Maternal and Child Health (MCH), (c) Leprosy Control, (d) Tuberculosis (TB) Control, (e) Malaria Control and (f) Blindness Control, the emphasis is largely on FP/ MCH programs. Reporting: the basis The starting point was the existent reporting management information system (MIS), which was sharpened, with resulting reports exchanged monthly. The reports were of six programs for all areas, comparing performance to targets, and integrating program components into one single measure by weights. The six programs, viz. FP, MCH, TB, leprosy, malaria, blindness, were selected on the basis of a consensus of District Health Officers on the program’s priority and the coverage possible with the resources allocated. Criteria such as importance of the result, verifiability and scope for quick improvement guided the choice of indicators from existing reports. For the six programs, 39 indicators were identified as those on which the MIS should concentrate. Targets were fixed for all indicators, which can be grouped into two categories: (a) those in the nature of norms (e.g. case-holding rate for treatment to be 90070 for lepromatous patients); (b) those where increased coverage was sought (e.g. immunization, cataract surgery). These targets were established according to a variety of considerations, such as the feasibility of a quick improvement, the most productive district unit or the best performance by a health worker in the past 3 years. Maharashtra’s experience has underlined the need for substantial investment of time and analysis (a) in setting the targets, so that they are recognized as being reasonable, Int J Gynecol
Obstet 30
and (b) in securing acceptance from the managers and staff of the programs, down the line; only then could they be fully motivated. For the State as a whole and even more importantly for interdistrict comparisons, weights needed to be assigned to each indicator to be able to arrive at some appreciation of a program’s performance trends over the year. Equally, weights (however arbitrary) were useful for the individual programs, not so much to ‘measure’ overall State health performance as to facilitate inter-district comparison of their effort as a whole. The program weights adopted were: FP, 40; MCH, 20; TB, 11; leprosy, 14; malaria, 10; and blindness, 5. Experience has shown that assigning weights has enabled Maharashtra to handle a multiplicity of objectives satisfactorily, whereas in the past, during FP drives, or campaigns for any single program, all the others suffered. The information system presents the entire compilation of reports focusing on comparisons and rankings, which are reviewed on a regular monthly basis. At each level, the rank of health worker in comparison with his peers is available; thus, between Regional Deputy Director, Deputy Director, District Health Officer, Primary Health Center physician and Auxiliary Nurse Midwives (ANMs) and their opposite numbers in the same or other districts, output is compared. Each health worker/manager is aware of his ranking and productivity as compared with others in each individual program. The management process Analysis, review and training The program used a specific format for analysis of information, focusing particularly on poor performance. This resulted in a battery of questions, a kind of ‘public health audit.’ It was characterized by the constant search for causes of unsatisfactory functioning in different areas and at various time of year, or in various programs. The
Peer reviewamong DistrictHealth Officers
health workers involved have, through discussion and exchange of views and analyses, been able as a group to develop far more desirable approaches to each of the program components, and to gain greater insight into the limiting conditions of these interventions. The systematic monthly peer review at each operational level leads to greatly improved skills and professionalism. Corrective action The specified format, along with an analysis of causes, also leads to proposals for corrective action, consisting of changes in policies and procedures, field visits to less productive districts and solutions to field problems. This constant emphasis on analysis and proposals for corrective action has led to a large number of administrative and policy measures that have considerably increased the output of the health care delivery system. Dealing with problems where they occur has also substantially raised staff morale, since the isolation once felt by every worker and manager far from headquarters is reduced, as he realizes that his concerns are addressed. Motivation (a) District ranking has been the most effective instrument for the manager’s selfevaluation and for the Director’s supervision over the field machinery. Therefore ranking has been extended to lower levels, to the medical officers in-charge of PHCs within the district and the Multipurpose Workers (MPWs)/ANMs of sub-centers within the PHC. (b) The ranked presentation of performance has been found to be extremely stimulating; those who do well want to maintain their standing. Those who do not, either increase their efforts or point out difficulties and suggest ways of removing obstacles. (c) The prompt feedback of ranking before the next reporting period has ensured that competing professionals can effectively modify their performance without delay. (d) Linking rewards to performance:
35
ranking and feedback would be quite ineffective if better performance were not rewarded. We have used annual ranking as the main (but not the sole) basis for annual evaluation. Some of the incentives were: study tours abroad; fellowships for study abroad; selection for post-graduate training; postings to preferred locales; and accelerated or out-ofturn promotion. (e) To ensure that local elected officials take greater pride, responsibility and involvement in the results, the District Health Officers are required to give a quarterly report to the Zilla Parishad, the local body controlling the Community Health Volunteers. (f) Quality control: we were aware that in any system pressing for results, there was not only the possibility of fraud but also of deterioration of quality (e.g. men or women outside the reproductive age group undergo sterilization; poor operating conditions in surgical camps). Therefore, we stepped up our quality control by a variety of such measures as monitoring indices (viz. complications during surgery), annual random surveys, special training programs and strengthening supervisory staff. Results and limitations The management information system described was very productive. Four important aspects of the program should be noted: -
-
-
Results: achieved in a very short time, about a year and a half. Cost: very little increase in inputs, the meeting time. Quality: maintained as evidenced by measures such as death/complication rate in eye operation/sterilization. Other programs: unaffected by focus on single program; family planning drive was achieved without sacrificing, in fact while expanding dramatically, the performance in other programs. Conference Proceedings
36
Srinivasan
Table I.
Primary health care performance indices, Maharashtra State, India, April 1980 to March 1982.
Index
April 1980 to March 1981
April 1981 to March 1982 No.
1. PP sterilizations 2. DPT (3 doses) 3. TT to expectant mothers (2 doses + booster) 4. Cataract operations 5. BCG vaccination to children (O-l) 6. New TB case detection I. New leprosy case detection 8. Percentage of infectious leprosy cases under regular treatment 9 Positivity rate for malaria
Percentage increase
311,877 848,227 787,002
491,726 l&2,352 1,250,894
58 70 59
10,922 311.390
103,322 1,187,348
846 281
50,794
137,258 67,491 87
170 44 43
46,751 61
3.0
1.6
-47
DPT = diphtheria, pertussis, tetanus vaccine; TT = tetanus toxoid vaccine; BCG = Bacillus Calmette-Guerin vaccine. Source: Srimvasan V: Management Information Systems on Health Programmes in Maharashtra. Economic Development Institute Training Materials, Case Study and Exercise Series, PD-530-7-PI. The World Bank, Washington, DC, 1982.
The improvement in performance indices for the State can be seen in Table I. The most important limitation of any such energization process is that, whatever the internal communication effort, the process is charged with being target-oriented. The substantive element of this criticism is that emphasis on numbers may be at the expense of quality. It is necessary to explain persistently that targets are necessary as goals to stimulate performance and achievement of numbers is not necessarily at the expense of quality. Maintaining communication is critical to avoiding a backlash. How has MIS achieved results? The conclusion we have drawn from our analysis is that the system presented helped the junior medical officers, the District Health Officers and District Medical Officers and the top management to achieve desired results, by an effective integration of the three components, viz. review, motivation and corrective action. But its most important aspect has been peer review and discussion at all levels and the training function that it fulfills. Our experience has been that the process Int J Gynecol Obstet 30
fails where it is restricted to top management, that it succeeds only when there is an internalization of the program’s approaches, information and lessons. The process of collecting and consolidating information, ranking, analysis and making program improvement decisions, feedback and corrective action has only limited use if it is restricted to top management. Its fullest benefits are derived only if the process extends to include meetings of peers at every level including the lowest level of field workers (ANMs and Community Health Volunteers) leading to their professionalization, skill upgrading and higher productivity and thus to potential improvement in the performance of the national system as a whole. Likewise, this success illustrates the point that the key to the effort is people, not technology, and that success lies in sharpening their skills, motivating them and enabling them to work effectively. Address for reprints: v. Srinivn!ian Africa Department Population, Health, Nutrition The World Bank 1818 H Street, N.W. Washington, DC 20433, USA
33
Peer review among District Health Officers in Maharashtra, India V. Srinivasan The World Bank, Washington, DC (USA)
Abstract A management information system in Maharashtra State, India, was used to obtain primary health care performance data for review at monthly meetings of peers, including District Health Officers, Auxiliary Nurse Midwives and Multipurpose Workers. The meetings were conducted in a problem solving, educational atmosphere. The effect of this process was marked improvement in health worker motivation andperformance. Keywords: Medical audit; Primary health care; Management information system. Primary Health Care (PHC) constitutes the single most important international health effort in the 1980s and simultaneously poses the greatest challenge. The main interventions for improved health such as provision of better maternity care, early treatment of diarrhea, complete immunization coverage of infants, health education and family planning are clear. But what appears to elude most large public systems is the capacity to deliver effective technologies/interventions over a whole population through large bureaucracies, and myriad service providers. How 0020-7292/89/$03.50
0 1989 International Federation of Gynecology and Obstetrics Published and Printed in Ireland
do we energize these systems? This paper attempts to describe and analyze some management responses to the question. The capacity of public bureaucracies is basically constrained by the system’s inability (a) to exchange information and to upgrade the skill8 of all members on a continuing basis; (b) to motivate the staff to perform; and (c) to provide, maintain and implement an environment in which corrective policy and action is continuously taken to maximize performance. The central difficulties are thus not so much generated by the medical technology as by the delivery system or institutional development. One successful example in which a conventional information system has been used by management to stimulate excellent PHC performance through a combination of peer review, motivation by ranking and reward, and pursuing corrective action is the case of Maharashtra, one of the constituent States of the Union of India, with a large public health system serving a population of around 62 million. The health delivery system in Maharashtra In rural areas the basic unit, the Primary Health Center (PHC), covers approximately 100,000 people. These PHCs are run by Conference Proceedings
34
Srinivasan
locally elected bodies with a District Health Officer (DHO) supervising the health personnel. One Community Health Volunteer per 1000 population, chosen by the community, is not an employee of the government. While the principal health programs implemented in Maharashtra are (a) Family Planning (FP), (b) Maternal and Child Health (MCH), (c) Leprosy Control, (d) Tuberculosis (TB) Control, (e) Malaria Control and (f) Blindness Control, the emphasis is largely on FP/ MCH programs. Reporting: the basis The starting point was the existent reporting management information system (MIS), which was sharpened, with resulting reports exchanged monthly. The reports were of six programs for all areas, comparing performance to targets, and integrating program components into one single measure by weights. The six programs, viz. FP, MCH, TB, leprosy, malaria, blindness, were selected on the basis of a consensus of District Health Officers on the program’s priority and the coverage possible with the resources allocated. Criteria such as importance of the result, verifiability and scope for quick improvement guided the choice of indicators from existing reports. For the six programs, 39 indicators were identified as those on which the MIS should concentrate. Targets were fixed for all indicators, which can be grouped into two categories: (a) those in the nature of norms (e.g. case-holding rate for treatment to be 90070 for lepromatous patients); (b) those where increased coverage was sought (e.g. immunization, cataract surgery). These targets were established according to a variety of considerations, such as the feasibility of a quick improvement, the most productive district unit or the best performance by a health worker in the past 3 years. Maharashtra’s experience has underlined the need for substantial investment of time and analysis (a) in setting the targets, so that they are recognized as being reasonable, Int J Gynecol
Obstet 30
and (b) in securing acceptance from the managers and staff of the programs, down the line; only then could they be fully motivated. For the State as a whole and even more importantly for interdistrict comparisons, weights needed to be assigned to each indicator to be able to arrive at some appreciation of a program’s performance trends over the year. Equally, weights (however arbitrary) were useful for the individual programs, not so much to ‘measure’ overall State health performance as to facilitate inter-district comparison of their effort as a whole. The program weights adopted were: FP, 40; MCH, 20; TB, 11; leprosy, 14; malaria, 10; and blindness, 5. Experience has shown that assigning weights has enabled Maharashtra to handle a multiplicity of objectives satisfactorily, whereas in the past, during FP drives, or campaigns for any single program, all the others suffered. The information system presents the entire compilation of reports focusing on comparisons and rankings, which are reviewed on a regular monthly basis. At each level, the rank of health worker in comparison with his peers is available; thus, between Regional Deputy Director, Deputy Director, District Health Officer, Primary Health Center physician and Auxiliary Nurse Midwives (ANMs) and their opposite numbers in the same or other districts, output is compared. Each health worker/manager is aware of his ranking and productivity as compared with others in each individual program. The management process Analysis, review and training The program used a specific format for analysis of information, focusing particularly on poor performance. This resulted in a battery of questions, a kind of ‘public health audit.’ It was characterized by the constant search for causes of unsatisfactory functioning in different areas and at various time of year, or in various programs. The
Peer reviewamong DistrictHealth Officers
health workers involved have, through discussion and exchange of views and analyses, been able as a group to develop far more desirable approaches to each of the program components, and to gain greater insight into the limiting conditions of these interventions. The systematic monthly peer review at each operational level leads to greatly improved skills and professionalism. Corrective action The specified format, along with an analysis of causes, also leads to proposals for corrective action, consisting of changes in policies and procedures, field visits to less productive districts and solutions to field problems. This constant emphasis on analysis and proposals for corrective action has led to a large number of administrative and policy measures that have considerably increased the output of the health care delivery system. Dealing with problems where they occur has also substantially raised staff morale, since the isolation once felt by every worker and manager far from headquarters is reduced, as he realizes that his concerns are addressed. Motivation (a) District ranking has been the most effective instrument for the manager’s selfevaluation and for the Director’s supervision over the field machinery. Therefore ranking has been extended to lower levels, to the medical officers in-charge of PHCs within the district and the Multipurpose Workers (MPWs)/ANMs of sub-centers within the PHC. (b) The ranked presentation of performance has been found to be extremely stimulating; those who do well want to maintain their standing. Those who do not, either increase their efforts or point out difficulties and suggest ways of removing obstacles. (c) The prompt feedback of ranking before the next reporting period has ensured that competing professionals can effectively modify their performance without delay. (d) Linking rewards to performance:
35
ranking and feedback would be quite ineffective if better performance were not rewarded. We have used annual ranking as the main (but not the sole) basis for annual evaluation. Some of the incentives were: study tours abroad; fellowships for study abroad; selection for post-graduate training; postings to preferred locales; and accelerated or out-ofturn promotion. (e) To ensure that local elected officials take greater pride, responsibility and involvement in the results, the District Health Officers are required to give a quarterly report to the Zilla Parishad, the local body controlling the Community Health Volunteers. (f) Quality control: we were aware that in any system pressing for results, there was not only the possibility of fraud but also of deterioration of quality (e.g. men or women outside the reproductive age group undergo sterilization; poor operating conditions in surgical camps). Therefore, we stepped up our quality control by a variety of such measures as monitoring indices (viz. complications during surgery), annual random surveys, special training programs and strengthening supervisory staff. Results and limitations The management information system described was very productive. Four important aspects of the program should be noted: -
-
-
Results: achieved in a very short time, about a year and a half. Cost: very little increase in inputs, the meeting time. Quality: maintained as evidenced by measures such as death/complication rate in eye operation/sterilization. Other programs: unaffected by focus on single program; family planning drive was achieved without sacrificing, in fact while expanding dramatically, the performance in other programs. Conference Proceedings
36
Srinivasan
Table I.
Primary health care performance indices, Maharashtra State, India, April 1980 to March 1982.
Index
April 1980 to March 1981
April 1981 to March 1982 No.
1. PP sterilizations 2. DPT (3 doses) 3. TT to expectant mothers (2 doses + booster) 4. Cataract operations 5. BCG vaccination to children (O-l) 6. New TB case detection I. New leprosy case detection 8. Percentage of infectious leprosy cases under regular treatment 9 Positivity rate for malaria
Percentage increase
311,877 848,227 787,002
491,726 l&2,352 1,250,894
58 70 59
10,922 311.390
103,322 1,187,348
846 281
50,794
137,258 67,491 87
170 44 43
46,751 61
3.0
1.6
-47
DPT = diphtheria, pertussis, tetanus vaccine; TT = tetanus toxoid vaccine; BCG = Bacillus Calmette-Guerin vaccine. Source: Srimvasan V: Management Information Systems on Health Programmes in Maharashtra. Economic Development Institute Training Materials, Case Study and Exercise Series, PD-530-7-PI. The World Bank, Washington, DC, 1982.
The improvement in performance indices for the State can be seen in Table I. The most important limitation of any such energization process is that, whatever the internal communication effort, the process is charged with being target-oriented. The substantive element of this criticism is that emphasis on numbers may be at the expense of quality. It is necessary to explain persistently that targets are necessary as goals to stimulate performance and achievement of numbers is not necessarily at the expense of quality. Maintaining communication is critical to avoiding a backlash. How has MIS achieved results? The conclusion we have drawn from our analysis is that the system presented helped the junior medical officers, the District Health Officers and District Medical Officers and the top management to achieve desired results, by an effective integration of the three components, viz. review, motivation and corrective action. But its most important aspect has been peer review and discussion at all levels and the training function that it fulfills. Our experience has been that the process Int J Gynecol Obstet 30
fails where it is restricted to top management, that it succeeds only when there is an internalization of the program’s approaches, information and lessons. The process of collecting and consolidating information, ranking, analysis and making program improvement decisions, feedback and corrective action has only limited use if it is restricted to top management. Its fullest benefits are derived only if the process extends to include meetings of peers at every level including the lowest level of field workers (ANMs and Community Health Volunteers) leading to their professionalization, skill upgrading and higher productivity and thus to potential improvement in the performance of the national system as a whole. Likewise, this success illustrates the point that the key to the effort is people, not technology, and that success lies in sharpening their skills, motivating them and enabling them to work effectively. Address for reprints: v. Srinivn!ian Africa Department Population, Health, Nutrition The World Bank 1818 H Street, N.W. Washington, DC 20433, USA