State Health Resource Center

The State Health Resource Centre ,is a autonomous organization which plays the role as an “Additional technical capacity to the department of health and family welfare Chhattisgarh”. Its role in initiating and sustaining the Mitanin program, its role in supporting the health sector reform agenda and in launching innovative and technically sound new program initiatives. Chhattisgarh has been acknowledged widely its owes its effectiveness to its institutional structure, its policies on its own human resource development.

The SHRC is developing a program and is being strengthened to respond to request from other state to assist them in this effort

In March, 2002, RCH Society, Chhattisgarh and the Regional Office (Raipur) of ActionAid India Society (AAI) executed an MoU. The MoU was signed in the context of European Commission assisted Sector Investment Programme (SIP) and State Health Resource Centre, Chhattisgarh was to function as “additional technical capacity to the Department of Health & Family Welfare in designing the reform agenda developing operational guidelines for implementation of reform programme and arranging / providing on-going technical supporting to the District Health Administration and other programme managers in implementing this reform programme.”

With regard to setting up the SHRC, the role of AAI was defined in para 4.1 and 4.2 of the MoU as follows:

“4.1 The AAI will set up and manage a State Health Resource Centre (SHRC). In this regard, the AAI will:

¨ ¨ set up the physical infrastructure for the SHRC,

¨ ¨ recruit experts and support staff for the SHRC, as provided for in the budget and agreed upon with the RCHS,

¨ ¨ arrange for the induction, training, exposure and capacity building inputs of SHRC experts and staff,

¨ ¨ evolve systems for the effective functioning of the SHRC. More specifically, AAI will develop all systems/ manuals/ policies for smooth functioning of the SHRC. In the first six months, AAI will develop, amongst other systems, the following:

¨ ¨ Accounting and Auditing Standards Manual

¨ ¨ HR Policies and Procedures Manual

¨ ¨ Operations Manual

¨ ¨ Gender Policy Manual

¨ ¨ provide administration inputs to the SHRC as required from time to time, and

¨ ¨ review periodically the functioning of the SHRC.

4.2 In addition to managing the SHRC, the AAI has agreed to perform the following other tasks:

¨ ¨ Facilitate, on behalf of the GOC, the development of operational framework for forging partnerships with NGOs, CBOs and people’s movements for effective implementation of the reforms process.

¨ ¨ Conduct independent reviews of the intensity and direction of the reform process on behalf of the GOC.

¨ ¨ Co-ordinate with the State Resource Group, which is an advisory body comprising health activists, community health practitioners, NGOs, CBOs and human rights organisations based in Chhattisgarh.”

Defining the SHRC’s roles

The SHRC, Chhattisgarh has been called upon to play the following roles:

· · Assist the department in evolving projects and programmes and in providing strategic analyses that would guide planning.

· · Develop guidelines, communication material, draft orders etc for approved innovative projects and health sector reform strategies that have to be rolled out.

· · Locate and contract in suitable technical expertise to work with state teams to develop proposals, evaluate programmes or aid implementation.

· · Undertake formative and operational research and rapid programme appraisals so as to make planning evidence based and so as to assess progress and institute correctional measures.

· · Support the directorate and implementation authorities in monitoring reform measures, troubleshooting problems and building consensus and providing internal advocacy for reform measures at various stages of implementation. This role may be described as that of an internal “champion”( proactive supporter) of reform

· · Sustain civil society participation in reform process and ensure that partnership programmes succeed. For example, the NRHM is promoting a number of committees- state and district health societies, hospital development committees etc- but there has to be a champion of ensuring that the public does participate and that such participation has sufficient quality and that the usual hesitations to letting the public into public health are overcome.

· · Undertake financial planning and management support for new and innovative programmes of a sort that the department is unused to running. Such management functions may be on a turnkey mode- with the directorate enabled to take up the activity soon once they the systems of management are established.

One major example of SHRC role has been is in the Mitanin Programme where it built up an innovative and locally adapted programme design, helped find and support people within the government to play leadership roles, brought in and trained the best elements within civil soceity, scientifically evaluated the programme and based on feedback improved on design, trained the trainers and even routed the funds to the district health societies and built up flexible and rigorous accounting procedures that ensured that expenditure and utilization certificates broadly came on time.

Another very different example of the change management role is with regard to training for short term life saving skill training in emergency obstetrics. The SHRC negotiated with health facilities and professional bodies to initiate the training, convinced key players in the districts and in the directorate of the need for this approach, built up evaluation and support systems so that the initial poor results of this approach were overcome even as the programme had to be defended against internal cynicism and provided personal support to the trainees till at least some of them started providing emergency obstetric services.

There are many more examples- big and small- of the diverse catalyst roles that are needed and today it is inconceivable to think of health sector reform without such drivers for change. Whether it is changing prescription practices of doctors or procurement practices of the administration, whether it is introducing new training programmes or ensuring that BCC programmes conform to a scientific implementation framework, change does not happen only on the basis of right thinking and capacity building. Change requires having to contend with existing knowledge and mindsets and institutional structures and the SHRC must be created to contribute to such a role.

SHRC as institutional innovation:

Institutionally, therefore, the SHRC is unique and has the following specific features:

· · It is an autonomous body with its own governing body and executive committee and its rules and regulations. The government has sufficient representation in it to ensure transparency of all its operations and to intervene is there are problems that need such assistance. But all recruitments, contracts etc for the SHRC team are done autonomously and independent of the government.

· · The SHRC is assigned tasks which it has to deliver in a time bound manner. There are a set of long term tasks ( like the Mitanin Programme ) and many immediate tasks that the government assigns to it from time to time. The MOU is renewed if the government is satisfied with the SHRC’s performance on these tasks. The SHRC is not bound to accept all tasks and can potentially refuse tasks that it feels is beyond it or that it does not agree with – though in practice such a clause has never had to be exercised.

· · The SHRC has no authority over the government officers or implementation authorities. It is purely facilitatory and advisory in nature. This prevents it from becoming a parallel authority and prevents contestations of power that are the bane of other institutional arrangements. Its effectiveness is derived from the quality of inputs it provides and its ability to internally champion processes of change.

· · The SHRC, however, has a ‘note-sheet’ level relationship with the directorate and department and the state health society so that its advice is available in a routine manner, on a wide number of issues and forms part of the official records. The SHRC faculty may be assigned specific monitoring or coordination tasks by the directorates as nodal officers where need arises.

· · In view of the unique nature of demands made on the organization and also due to the considerable capacities needed in house, the SHRC has had to evolve an innovative and appropriate set of HR policies that brings in, builds and retain talents. Typically, SHRC faculty turnover is low, and the work culture and collective decision making and opportunity to learn provides an alternative to the high salaries that other comparable institutes offer and which SHRC itself can ill afford.

SHRC as a process

As mentioned above, the SHRC was established through a ‘host’ NGO which then had experienced officers who had worked closely with the government. The partnership with the NGO –ActionAid in our case – was formalized through a MoU which mandated the NGO to set up and manage the SHRC for and on behalf of the State, till it could be a truly autonomous institution.

The decision to engage a ‘host’ organization guaranteed the freedom of being able to find the right initial persons and build the team for the SHRC. There was also considerable flexibility to head hunt for suitable persons to constitute the initial team.

To ensure that the SHRC had a character of an organization working for change, and for reaching health care to the poor, the governing body was evolved out of a number of individuals and organizations known to be committed to such values and who had a good track record of supporting institutional development. The NGOs who were interested and who participated in the formulation of a health sector reform strategy were constituted into a state advisory committee for health sector reform and with their support the governing body was constituted. The executive committee was made of those who were part of the full time team.

Knowing the lack of skilled persons who would be available to work in the EAG states at the pay scales that we could offer (comparable or marginally higher than government scales – but not certainly at international agency pay scales)- the SHRC followed a policy of recruiting persons with the right mix of background and motivation and building up their capacities in house. This required a certain type of leadership and great emphasis on mentoring arrangements.

Knowing that this work requires experience and expertise on a wide number of areas, and it would not be possible to hire persons with such experience, the SHRC followed a policy of ‘contracting-in’ experts to work with its team and recorded this experience of working together in its institutional memory so that the expertise available locally increased cumulatively.

“Managing change” requires patience and persistence, the ability to withstand criticism and sometimes hostility both from within (the government) as well as from without (e.g. civil society organisations’ initial refrain that the Mitanin initiative represented government’s intention to ‘withdraw’ from its public health responsibility). The change agents, at the same time, need to understand and negotiate with different points of view, take various initiatives and risks when no one else is ready to do so and yet understand that “success” requires ownership of the idea and the work by others- sometimes to the exclusion of the main movers. The SHRC, therefore needed to build-in a strong element of networking with similar minded individuals and organizations both in the state and national level, so that there was mutual solidarity and a specially created peer support for supporting the change process.

The bottom-line of SHRC experience, in other words, is not just about ‘establishing’ yet another structure but finding a suitable NGO and formalizing a partnership with it which allows the NGO partner sufficient flexibility in finding the right individuals who would become a team in supporting the State Directorate / SIHFW / State Society on an on-going basis.