Integration in the Context of Implementing the NRHM Mandate

1. Integration in the Context of Implementing the NRHM Mandate NHSRC & CSMCH-JNU Collaborative Workshop 18th-19th August, 2008 Ritu Priya & T. SundararamanNHSRC

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13. NRHM as contested terrain�. Between public provisioning of health services with public financing versus private provisioning with public financing (and public provisioning with part private financing eg user fees)!!! Between a vertical centralised health programme led approach with systems back up versus decentralised systems-led approach with increasing integration of programmes. Between a sovereign self-reliant catch up with the world based on the global best in knowledge and a decentralised model of knowledge generation, versus dependence on donors for technical assistance and funds with a vertical model of knowledge diffusion. 13

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15. The NRHM Additionality Approach Parts A, C & D as primary focus: RCH-II, Immunization and Disease control programmes: (Malaria, tuberculosis, Leprosy, HIV) All the above governed by international agreements All the above vertical All of which signed before NRHM All of which dependent on externally funded technical assistance PLUS Part B: NRHM additionalities, to attend to health systems issues that limit effectiveness of the national health programmes. PLUS: Health related sectors: very much of a token presence in deference to political sensibilities 15

16.  NRHM � as health systems strengthening approach NRHM seeks to strengthen state health systems. Health programmes would increasingly get integrated into it. Increasingly stand alone programmes would not be necessary as �facilities and outreach programmes� become fully functional, integrated, comprehensive. Also they would become unnecessary as some of the current priorities are achieved and contribute less to burden of disease eg leprosy, polio� This would facilitate decentralisation where centre�s role would be limited to defining standards, channelisation of finances and technical resources to prevent uneven/inequitous development. Safeguard equity and quality. 16

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24. Disease control: Positive Impact of NRHM on malaria and kala-azar control The control of malaria and Kala-azar received priority in areas where these diseases are prevalent. Strengthened by the introduction of ASHA, Strengthening by filling up of MPW vacancies Strengthened by filling up medical officer vacancies Strengthened by improvement of laboratories . Work on the elimination of kala-azar accelerated. provision of free transport, free testing, free supply of drugs, and free diet to patient attendants and payment of Rs. 50 per day for the loss of wages. All the PHCs visited have admitted Kala-azar patients, tested the patients and confirmed cases are treated as per the protocols. Adequate arrangement has been made for treatment, assured drug supply and financial support for patients and one attendant. 24

25. Janini Suraksha Yojana One of the public faces of NRHM �Conditional cash transfer� approach acts as an incentive to bring a flood of new users into public health systems. Forces attention on issues of access to care, quality of care, on issues of human resource availability and on issues of infrastructure. 25

26. Potential Impact of JSY on health systems�. A. Increase public private partnerships. Strengthen emergency transport system.. Search for more opportunities for conditional cash transfers to achieve other programme goals. Provide more inputs to public facilities to improve quality of care and increase 24*7 delivery services, emergency obstetric care etc. Task shifting for achieving skills needed (human resources for maternal health), B. Using this as an opportunity for achieving �fully functional health facilities faster.� Solve human resources for public health by increasing nursing education and multi-skilling in major way; Supplementing gaps with private partnerships. Strengthen traditional birth attendant capacities with backup referral and emergency transport Strengthen emergency transport system.. Strengthen newborn and child care in PHCs and CHCs- providing minimum norms and support for the same. 26

27. Example: Child Health: Current: Begins with IMNCI. Immunisation: Vitamin A � in two drives. Zinc for diarrhoea. SNCU in some hospitals. Skilled birth assistance in some areas and �emonc� in some facilities. BCC, malnutrition and anemia missing.. School health.. Here and there, this and that.. Systems approach: Begin with protocols for ASHA(Home based care for sick child), for AWW(IMNCI), for subcenter(IMNCI), fro PHC(SNCU-1) for CHC(SNCU-2) and for DH(SNCU-3) and for school health Build in Nutrition Rehab. Centres Skill and support health care providers to deliver these services Build up logistics to support it. Build up BCC and community mobilisation to support it including VHND strategy> Monitor and support these services. Build up a district resource team and management team to lead all of this: (vitamin A and immunisation part of sub-center protocol, zinc part of IMNCI) 27

28. What drives vertical programmes� The central state- divide where the central funding determines key programmes while state funding is limited to salaries/establishment. The influence of donor agreements and their priorities. The structures and privileges that have developed over time vested in vertical structures. An ideological perspective that public intervention should be limited to few cost effective programmes for few pragmatic internationally prioritized objectives- not try to provide �everything for everyone� and to leave other private care to market forces. An understanding/influence that prioritizes those investments in public health that help develop markets- for products, for services.., with a bias towards markets for corporate structures.. 28

29. How do we articulate needs for integration: without challenging the ideological perspective Monitoring: how monitoring of each programme depends on the other and is more efficient and effective: How it can, in turn, be used to promote better management and achieve convergence. Human Resource Development: all programmes need doctors , nurses, health workers, managers: tendency to grab those available for vertical priorities. But yet without a common plan for development of health resources it is almost impossible to develop these resources- and without synergy one cannot rationalize use. Human Resource Development: Skill development: not possible to access in-service human resources for skill development without synergy. Planning- especially district level and village level: why it is needed for more effective vertical programmes , and in turn how its leads to better allocation of resources. Infrastructure planning: Funds available for infrastructure from each programme can be leveraged for all without sacrificing commitments to funding agency. 29

30. ISSUES How do we look at non-communicable disease programme.. Can we have national cancer control programme, national diabetes control programme, national goiter control programme, national cardiovascular disease control programme, national fluorosis control programme, national mental health programme, national dental health programme, national epilepsy control, national anti snake bite programme etc etc? Should we limit all the above programmes to only providing research and resource inputs and insist on integration of all these? Current national programmes account for only 19% of morbidities- what about the rest.. Needs to be built into the concept of Fully Functional Health Facilities- & Indian Public Health Standards 30

31. What could be an alternative perspective on integration and convergence? A. Health systems development is the main approach with health programmes being interim measures. B.District Health Systems development is needed because it can lead towards: Decentralised governance Public participation in health governance. A citizen-responsive health system. A more effective and equitable health system. A more rational and cost-effective health care system. 31

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34. Thank You 34