Understanding social organisation and delivery of integration for NCDs programmes in Bihar, India: An institutional ethnography

Abstract

In the health systems literature, integration has been proposed as a management strategy to increase access to services, improve patients’ satisfaction, enhance quality of care, reduce costs, and increase organizational efficiency. Empirical literature shows that availability of qualified and motivated staffs, drugs supply, and adequate infrastructure are key barriers for success of integrated programme low income setting. Understanding these barriers and related institutional process can bring new perspective and insight on integration. This dissertation examines the implementation of integrated NCDs and mental health programmes in Bihar from health workers’ standpoint. The study employs Institutional ethnography (IE) to guide this inquiry, a methodology that begins with the everyday experience of participants (health workers and managers in the integrated programmes) and then moves outwards to examine the social organization of programmes as they are implemented within the health system. Data collection was conducted in four sites in Bihar state (West Champaran, East Champaran, Vaishali, and Patna) and included 27 in-depth interviews with health workers and managers, 12 observations at three-district hospital and an analysis of 48 documents (guidelines, file notes, meeting notes and letters). Analytical writing, textual analysis and mapping were used as iterative and reflexive processes to map institutional relations in the integrated NCDs and mental health programmes. The study shows that integrated programmes are implemented in the decentralised health care context, where district administrators have limited authority. The analysis of institutional texts shows the principles of accountability, transparency and administrative govern institutional processes of staff recruitment and drug procurement and in turn, influence care pathways and service delivery. Some of integrated programme staffs were removed from the NCDs and mental health programmes and deployed in other priority programmes which negatively impacted NCDs and mental health service delivery at district hospital. Sometime staffs are forced to work in emergency ward without having proper skill and knowledge, which undermines the safety and quality of services. The study recommends that central government should give more autonomy to district authority to manage the institutional task of staff recruitment and drug procurement. The policy maker should develop human resource policy to provide better work condition to health workers working at the district hospital.