NRHM

1. Meeting People’s Health Needs NRHM 21st October 2008 UN/ISRO India Regional Workshop on Using Space Technology for Tele Epidemiology to benefit Asia and the Pacific Regions National Rural Health Mission Ministry of Health & Family Welfare Government of India

2. India – an overview • Structure of Health Sector • Status of Health • Health Sector Rejuvenation • NRHM – Brief outline • eHealth – Brief outline • Technabling the NRHM • Really beyond the existing mandate of Group 6. However, Public Health is the central theme and sat tech is an important tool for the same. Group 6 may decide to realign its mandate in view of the ground realities in developing countries.

3. We turned Billionaire seven years ago We’re now over1.1 Billion

4. India - Overview States & UTs28+7 Villages 6,00,000 Blocks6500 District615

5. Administration Overview States & UTs28+7 Villages 6,00,000 Gram Sabha Panchayat (Local Self Govt) Block Panchayat Blocks6500 Zila Parishad Municipalities, Cantonment Boards, Corporations, Town Area Commtt etc District615 State Legislature National Parliament

6. Health Sector (Public) Overview States & UTs28+7 Villages 6,00,000 Health Sub-centre 1,45,000 Primary H Centre 22,370 Blocks6500 Community Health Centre 4045 District Hospitals 585 District615 Sub Divisional, Taluk , Civil , TB etc Tertiary centres, medical colleges, GoI Hospitals

7. Structure of Health sector in India

8. Health delivery apparatus • Public Sector facilities • Private Practitioners • ESI, CGHS, PSU Hospitals • Railways Hospitals • Armed Forces Medical Services • Corporate Hospitals • Indian System of medicine • Informal providers • Quacks/Crooks & magico religious practitioners

9. Sub-Centre (SCs) Most peripheral contact point with primary health system One ANM and one Male Health Worker One Lady Health Worker (LHV) supervises six Sub-Centres. Tasks relating to interpersonal communication wrt maternal and child health, family welfare, nutrition, immunization, diarrhea control and control of communicable diseases programmes. Provided with basic drugs 100% Central assistance to all the Sub-Centres since April 2002 There are 1,45,272 Sub Centre as on March, 2007

10. Primary Health Centre (PHCs) First contact point with Medical Officer. Envisaged to provide an integrated curative and preventive care Established and maintained by the State Governments underthe Minimum Needs Programme (MNP) Manned by a Medical Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 Sub Centres. It has 4 - 6 beds for patients. There are 22,370 PHCs as on March, 2007 in the country

11. Community Health Centre (CHCs) Established and maintained by the State Government under MNP/BMS programme . It is manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff. It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory facilities. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. As on March, 2007, there are 4045 CHCs functioning.

12. Structure of Public Health System • Health is a State Subject Family Welfare is Concurrent. • Primary Health care is Local self Government. • Most institutions and manpower are state property. • Most programmes are in the central initiatives. • National Programmes address only 25% of all morbidities. • .59 doctors, 0.8 nurses and 0.47 Midwives per 1000 population 1.86 health worker /1000 • No dedicated health functionary at village level. • First functionary at Sub Centre level (5000 population) • First doctor only at PHC (30,000 population) • First specialist only at CHC (80,000 population)

13. Deep rooted structural issues • Sustainable Systems • Financing 5.2 % of GDP ( Private 4.3 %, Public 0.9%) • Infrastructure (over 2,00,000 facilities yet inadequate) • Human Resources Workforce Issues: Irrational distribution; Poor work culture; absenteeism; Poor supervision • Logistics, Management and Evaluations • Equity and accountability • Non responsive to citizens

14. Statistics of Health sector in India

15. India’s survival challenge • Birth rate 24.1 (2004) • 27 million neonates to take care • U5MR 95 (1998-99) • 2.5 million die before completing 5 years • Globally India accounts for 23% of all U% deaths • IMR 57 (2007) • 1.6 million die before completing 1 year • 64% of infant deaths occur in the first 30 days. • NMR 40 (2002) • 1.1 million die before 4 weeks of age • Demographic transition If born in 2007 will live till 64 years old. 60 years ago expect to die at 32 years • 2nd largest number of elderly (60+) 24 million over 60 in 1961 to 77 million in 2001. • 17.5% India will be over 60 in 2050 (7.5% in 2001). NCD majorly influence well-being at old age.

16. H R Density / 1000 Population ( World Health Statistics - 2007 W H O )

17. National goals & MDG context

18. India’s Health Indicators Large inter state variations

19. Rapid economic growth Over past 16-17 years of reform. • Poverty incidence fallen About 36% in 93-94 to 28% in 04-05 • Educational opportunities have increased. • Little Improvement in Child malnutrition Among the highest in world In some states it has got worse. • Slow improvement in Health & nutrition indicators General paucity of health infrastructure at the village level. • Improved Immunization coverage 36% in 92-93 to 42% in 98-99 to 44% in 05-06. Actually fell (98-99 to 05-06) in Punjab, Haryana and Maharashtra. • Sex ratios have got worse

20. THE CITIZEN’S PERSPECTIVE Lack of Holistic Approach Health not a priority. Under funded, yet not utilised. Shortage of infrastructure & human resources Lack of community ownership Lack of accountability Lack of basic amenitiesfood drinking water Non integration of Disease Controlprogrammes Non responsivenessto Citizen

21. Something is changing in India

22. Average monthly patient attendance in PHCs in Bihar increased from 39 (per month) to over 3500 (per month) • Institutional delivery • Assam from 107,000 during 01-02 to 138,000 during 04 -05 & then to 265,000 during 07-08 • Bihar from 7,233 during July 06 to 47 thousand during July 07 • MP from 41% during 05-06 to 62% during 07-08 • Gujarat from 57% during 04-05 to 76% during 07-08 • Tamil Nadu Between 2002-03 to 2008-09, deliveries at • homes reduced from 9.9% to 1.11% • private facilities reduced from 39.9% to 34.64% • PHCs increased from 6.3% to 19.68% • (majority of this change being post 2005)

23. AP Rural Emergency Health Transport • Transport to pregnant women, infants, children & emergencies. • Toll-free No.108 365x24x7. • 502 ambulances in 1107 mandals. • Average time for reaching hospital 16 min. in Urban & 22 min. in Rural areas. • Total emergencies attended per day is 2,806 (97% are Medical) • In two years, REHTS has saved 20,394 lives by attending to them in the crucial Golden hour

24. What facilitated these changes ?

25. National Rural Health Mission launched in April, 2005 • Rejuvenate the Health delivery System • Universal Health Care • Access • Affordability • Equity • Quality • Reduce IMR, MMR,TFR • Improve Disease control • Overarching umbrella for all programmes

26. Goals of the Mission Universal Health care, well functioning health system. Reduce IMR to 30/1000 live births by 2012 Reduce MMR to 100/100,000 live births by 2012 TFR reduced to 2.1 by 2012 Reduce & sustain Malaria Mortality to 60% by 2012 Kala Azar eliminated by 2010, Filaria reduced by 80 % by 2010 Dengue Mortality reduced by 50% by 2012 TB DOTS maintain over 70 % case detection & 85% cure rate 46 lakh cataract operations annually by 2012. Upgrading all health facilities to IPHS. Increase utilization of FRUs from 20% bed occupancy to 75%

27. NRHM – the recipe • Over arching umbrella - sector wide – life cycle approach • Enhance funding to 2-3 % GDP • Architectural corrections in delivery system – reform agenda • Non negotiable service guarantees at all levels • Backward computing of budgets for entitlements. • Fund floats at local levels to kick start a rejuvenation • Blend dedicated budgets with untied, Flexible funds • Improve range-depth & quality of monitoring. • Community Health Worker • Capacity Building List ur Excuses and show them the door

28. The Paradigm Shift

29. The Paradigm Shift • Decentralised planning • Outputs and Outcome based • Pro-Poor Focus: Equitable systems • Quality of Care and the IPHS norms • Rights based service delivery • Pre stated entitlements at all levels • Inputs computed as function of the entitlements and estimated patient load • Judicious mix of dedicated budget lines - untied funds • Monitor quality • Community Participation

30. The Paradigm Shift • Bringing the public back into public health • At hamlet level : ASHA, VHSC, SHGs, Panchayats. • At the facility level: RKS • At the management level : health societies • Governance reform • Manpower, Logistics & Procurement processes. • Decision making processes • Institutional design, Accountability framework • Convergence • Water and sanitation • Nutrition • Education

32. Expanding Services at PHCsPHCs Operational 24 x 7 Non High Focus High Focus

33. Functional Referral ChainsFirst Referral Units Non High Focus High Focus

34. Local Management of FacilitiesRogi Kalyan Samiti High Focus Non High Focus

35. The Strategies

36. The Strategies • Infrastructure upgradation • Sub Centres made functional • Additional contractual ANMs • Untied funds • Community link worker • Village Health Nutrition committees • Expanded Medicines supply • PHCs made 24 x7 • Three staff nurses • Annual maintenance grant • Untied funds • AYUSH Integration • Rogi Kalyan Samiti

37. The Strategies • Infrastructure upgradation • CHCs upgradation • First Referral Units • Facility survey • IPHS • Untied funds • Rogi Kalyan Samiti • District Hospital upgradation • Facility survey • IPHS • Rogi Kalyan Samiti

38. The Strategies • Manpower augmentation • Filling up vacant posts/Creating more posts • Contractual positions to fill gaps • Trainings / expanding training capacity • Rational transfer and posting policy • Health sector planning • Household surveys & Village Health Plans. • Integrated District Health Action Plans. • Annual PIPs / Perspective Plans. • SPMUs/ DPMUs/ Block PMUs • NHSRC/ SHSRC

39. The Strategies • Improved service delivery • Citizen’s charter • Monthly Health & Nutrition Day • Outsourcing critical service gaps • Catch up rounds of Immunisation • Improved IP & OP utilisation • Mobility Support / Mobile Medical Units • Maternity Benefit Schemes • Systemic improvements • Improved logistics. • Rational / Optimal positioning of manpower • Rational delegation (financial & Administrative) • Decentralised procurement

40. The Strategies • Monitoring & Evaluation • Review meetings • State visits – evaluation teams, RDs • Integrated MIS • External Surveys • Immunisation - UNICEF • ASHA & JSY – UNICEF, UNFPA, GTZ • Financial protocols- Institute of Public Auditors • External Evaluations • Community monitoring • Encouraging State Innovations

41. Technabling the NRHM

42. e Health Advantages of telemedicine in rural areas Allows a referral chain Links the patients to urban standard services without delinking urban service providers from their mileu (CME can also continue simultaneously) Easier, cost effective consultation, prescription mechanism Disease surveillance and response at various levels.Limitations high initial cost , Licensing terms and conditions ,bilateral & Interconnection agreements, Non-Existence of Regulations Security, Legal &Trade Issues Also intersectoral convergence in health sector, sustainability, impersonal

43. Background • India – crucible for creating/testing/refining eHealth models. • Ideal settingfor telemedicine assisted health care. • Strong fiber backboneand indigenous satellitecommunication technology with large trained manpower. • Several pilot projects with successful outcome. • Ground work on telemedicine already laid partnerships with ISRO, DIT, States & specialty Institutes/hospitals. • Policy standardizationand infrastructuralissues researched. • Active Professional societies on e health. • Print and electronic media participatingin awareness

44. Lessons Learnt • Sub optimal IT infrastructurein Health sector • Vague in principlesupport for eHealth. • Poor acceptabilityof telemedicine by stakeholders. • Administrative and financial constraints. • Cost of equipments & skilled manpower still very high. • Domain skills often prevent learning of collateral skills.

45. National Rural Telemedicine Network

46. Design, development and implementation of low cost rural TM infrastructure • consisting of fixed, mobile and hand-held platforms and web technology based broad band wired / wireless wide area network centering around the district hospital acting as hub. • Design and development of Village Tele-ambulance System and rural emergency healthcare services / Trauma care module. • through mobile telemedicine network based on Wi-MAX wireless mesh network • Development of Rural Health Knowledge Resource • through web portal on public health domain and creation of e-CME module for it’s access by the stake holders through e-learning technology on the telemedicine platform • Development of technology for data harvest, compilation & storage • at regional district hub and central Data Center at MOH & FW, archive and distribution across network.

47. Structure of NRTN  LEVEL-1 PHC / CHC connected to a District Hospital LEVEL-2 DH connected to a State / National Specialty Hospital LEVEL-3 State / National Specialty Hospitals inter connected LEVEL-M Mobile Unit connected to PHC / CHC /DH

48. LEVEL-1 • Primary Health Center (PHC) / Community Health Center (CHC) / Village Unit • Tele-consultation room • Patient engagement facilities (bed, scopes, etc.) • Telemedicine Platform • Selective medical and medico-IT equipments, preferably IT compatible, with interface to Telemedicine and/or other software / hardware • Computer hardware / software platform (PC, switch, etc.) and IT electronics equipments • Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless) • Point-to-Point video-conferencing system (may be portable)

49. LEVEL-2 • District Hospital • Telemedicine room • Patient engagement facilities (bed, scopes, etc.) • Telemedicine Platform • medical and medico-IT equipments • Computer hardware / software platform • Connectivity / bandwidth requirements • ISDN, Leased line, VSAT, Broad band, Wireless • Multi-point video conferencing system

50. LEVEL-3 • State Hospital / National Super Specialty Hospital • Level 2 hardware/software • Optional secure centralized long-term electronic record storage for assigned LEVEL-1, LEVEL-2, and LEVEL-M units • Connectivity / bandwidth requirements (e.g. ISDN, Leased line, VSAT, Broadband, Wireless)