3 rd Common Review Mission UTTARAKHAND

1. 3rd Common Review MissionUTTARAKHAND December 22, 2009

2. Team MEMBERS • Dr. Manisha Malhotra, MOHFW, GoI • Dr. Anil Kumar, DGHS, MOHFW, GoI • Ms. Shagun Mehrotra, European Commission • Dr. Ravish Behal, RCH II TMSA • Ms. Deepika Shrivastava, UNICEF India • Dr. Abhijit Das, Centre for Health & Social Justice

3. Districts visited TehriGarhwal Almora

4. The following table shows : State Health Infrastructure

5. KEYINDICATORS

6. Key Observations

7. Infrastructure • NRHM contribution significant to infrastructure improvement • Inadequate infrastructure development plan • Facility planning / location – based more on land availability than on overall accessibility / need • Co location (e.g. PHC/SC and CHC/SC) & some clustering • State Allopathic Dispensaries not integrated into NRHM • Nomenclature of facilities not harmonised with GOI and IPHS • Availability of amenities: • power back up + ,cleanliness average, water shortages • Residential accommodation for providers by and large available at CHCs and PHCs – sometimes not occupied • Inadequate at District Hospitals and sub-centres • Temporary arrangements for attendants not available • Equipments: largely available, inadequately utilised • operating eye microscope, lift, inverter; lack of AMC arrangements • DHs and SDHs without functioning blood storage units/ blood banks • Mobility support for Block PHC MO I/C is inadequate - especially in hard to reach areas

8. Human Resources • Overall shortage of skilled human resources and difficulties in retention in hard to reach areas • Overall supply capacity low (5 ANMTCs recently revived, only one govt. medical college – set up recently) • Shortage of Anaesthetists in particular • Remuneration package not attractive and lower than neighbouring states • Delays in state recruitment processes-Doctors, ANMs and LTs • Inadequate promotion and professional growth avenues • In-service training at limited number of institutions, that are overstretched • Lack of training opportunities for MOs in hard to reach areas • Lack of integration/ institutionalisation of contractual employees • Mismatch in deployment of available resources • Post training deployment not utilising newly acquired skills e.g. LSAS trained MO in PHC and in CHC/FRU without complement of Ob-Gyn or Paediatrician; no Ob-Gyn in DH; Ob-Gyn in SDH not providing EmOC

9. Human Resources (contd..) • Positives /Steps taken: • New / renovated ANMTC, Medical college, and SIHFW coming up at D.Dun; tie up with MP for post-basic nursing education • Service providers, particularly MOs, and many ANMs possess reasonable knowledge and core skills ( despite lack of in-service training) • Skill-based training for MCH initiated.

10. Service Utilisation • Increase in case loads due to NRHM, JSY and ASHA • OP, IP, immunisation , institutional delivery, reduction in DOTS defaulters • Community expectation for service delivery increased • EMRI 108 Services universally used and appreciated • However difficulties in transporting women to roadheads • Timely JSY payments useful • Enhanced communication for service delivery • Publicising of mobile phone numbers • Sub optimal utilisation of DH / SDH/ District Female Hospital • lower delivery load than some PHCs • Inadequate preparedness of facilities for EmOC/ other emergencies/ Newborn care • Blood storage/ bank availability, lack of key service providers, no residential staff

11. Outreach Services • Village Health & Nutrition Days • Good session planning • organised in remote, underserved habitations • fixed day approach known to community • Good cross-sectoral linkages between frontline workers • Large thrust on immunisation; ANC and FP counselling, and B/F counselling to some extent • Nutrition counselling inadequate • Inadequate attention to growth monitoring and lack of knowledge on nutritional grading amongst ICDS functionaries • Inadequate monitoring of VHNDs • Mobile Medical Units • Systematically planned operation to provide maximum coverage of under-served areas (MMUs operated by Jain Video; HLFPPT) • Good OPD coverage (average attendance of 100 patients / day) • Availability of specialists and diagnostic facilities (X-ray, USG etc)

12. Quality of Services • Privacy in OPD and labour rooms + • Signage display (citizens charter, drug availability, JSY provisions, other IEC) prominent • 48 hours stay post delivery not consistently ensured (client insistence) • JSY: Public disclosure of beneficiaries not uniformly seen; grievance redressal mechanisms yet to be set up • IMEP / BMWM weak; no adherence to GoI protocols

13. Logistics & Supply Chain • Supply needs assessment and planning inadequate • Recent large supplies of Kit A, Kit B from GOI – MOs not informed of changes • Tedious procedures of procurement and distribution of supplies (60% done locally, 40% by state) • Cold chain was satisfactory in most facilities -however no generator, no temperature record in some (Barechina PHC ) • Nischay kits available in sub-centres and PHCs and being used.

14. Decentralisation / Local action • Utilisation of untied funds at PHCs and sub-centres appropriate • RKS / ChikitsaPrabandhan Samitis just being set up at PHCs • Members are primarily Government functionaries • MOs orientation on use of RKS funds inadequate • AMGs for PHCs –utilisation not decentralised • at places being managed by CMOs • Contractual MOs not involved in planning for AMG and Untied Fund expenditures • District Health Action Plans available • Inadequate analysis of district level issues • Inadequate involvement of PRIs/ CSOs/ user groups / Block MOIC / ANM/ASHA • VHSCs • In the process of being formed • Inadequate orientation of PRIs • Community monitoring not yet initiated

15. ASHA • ASHAs • Most visible face of NRHM • Completed all 5 training modules • High motivation and desire to be rooted in the health system. • ASHAs role and support well acknowledged by ANMs, ICDS AWWs, mothers communities • Adequate knowledge of MH services • Knowledge on CH / neonatal, nutrition counselling, and FP could be better • ASHA Resource Centre managed by distt MNGOs (Garhwal Community Development and Welfare Society (in Tehri) and INHERE (in Almora) • However, inadequate mentoring support to ASHAs at local levels- especially in hard to reach areas • Mechanisms in place for ensuring ASHA entitlements under JSY

16. RCH II • Institutional deliveries have increased • Voucher Scheme in 5 districts through PPP • JSY payments timely with a few exceptions ; no inconsistencies noted between number of deliveries and beneficiaries • Counselling on PNC, B/F etc. being largely provided at facilities • Immunisation coverage has improved • FP-Sterilisation inadequate- 9.8 % of target till now • Neonatal care- inadequate attention • Safe abortion services not available across facilities • Referral transport available through EMRI 108 –with excellent tracking mechanism • difficulty in transporting pregnant women in hard to reach areas to roadhead- need for Palki transport • Unmet reproductive health needs of women –specific concerns related to load bearing • Social factors- gender discrimination, multiple burden on women, lack of rest after delivery, poor nutrition

17. NDCPs • Slide examination for malaria inadequate – especially in terai area • No leprosy case under treatment in Almora; 3 cases in Tehri • 759 TB cases under treatment in Almora - but not seen as a priority • Integration of district level societies has not taken place

18. Programme Management • Roles and job responsibilities of DPMU not uniformly clear • Attrition, possibly due to low remuneration • Advertisements on website of SHFWS for BPM not sufficient to tap local candidates • Qualification requirements for BPMs higher than the local available capacities • Induction and refresher training not being carried out systematically

19. Financial Management • E-transfer of Funds at District, DH, SDH, CHC and PHC in practice; timely • Utilization Certificates are being sent only at the end of financial year • Release to districts: • RCH II – JSY, Sterilisation, rest lumpsum • Mission flexi pool – activity-wise • Immunisation – lumpsum • Individual NDCPs - lumpsum

20. Key Issues

21. KEY ISSUES • Excellent infrastructure underutilised due to • Poor geographical accessibility • Low catchment • Not providing full complement of services • Human Resource issues critical • Capacity Building (ANM, MO) will take time • Difficult area categorisation based on needs to be extended to sub-district/ block levels • Provider remuneration needs to be re-looked (lower than neighbouring states) • District institutions have inadequate load, hence cannot be used as sites for skill-based trainings • No clear plan for addressing neonatal mortality • Skill-based trainings, especially for MCH, to be fast tracked and linked to facility operationalisation plan • Performance based incentives for facilities to be re-looked. • Full complement of services not available at VHNDs

22. Recommendations

23. RECOMMENDATIONS • Overall orientation to NRHM and guidelines at all levels • Nomenclature and staffing of facilities as per GOI norms and IPHS • Infrastructure planning / location – needs to be linked to decentralised village microplanning/ tagging of hard to reach areas • Rationalise posting and transfers, improve incentives for hard to reach area within districts • Adapt recruitment procedures and requirements to tap and strengthen local capacity • Make 24x7 facilities fully operational and monitor them regularly • Improve range of Diagnostic facilities at all levels • Define opportunities for increasing contribution of SADs and AYUSH within NRHM eg. multi-skilling • Strengthen decentralized district planning processes, linking with other sectors –ICDS, TSC and expand planning to block and village level (bottom up) • Strengthen VHNDs with expanded activities e.g.GMP,Nutrition Counselling,referrals,salt testing • Greater orientation and sensitisation of PRIs and MOs for greater community ownership/communitisation

24. Recommendations (Contd..) • Consider District Resource Centre for NRHM which will guide overall training and communication • ASHA mentoring support to be extended through cluster level networking/ facilitation • Joint training eg.NRHM-ICDS-SWAJAL for improved convergent action • Simplify the procurement procedures on the pattern of Tamilnadu Health System Corporation model. • Develop systems for AMC of Equipments • Provide greater mobility support to MOIC for improved support to peripheral action • Develop common bio-medical waste management facilities in urban areas like Haldwani with linkages to hilly areas • Give more focussed attention to addressing neonatal health at the facility and community levels • Arrange hands on training for utilisation of HMIS for review and planning • Regular feedback from 108 about functioning of emergency and referral services • IEC activities to address social issues affecting the health of women

25. Policy Recommendations • Long term Human resource plan needed - • Capacity Building-Setting up of Medical Colleges, ANMTCs • Multiskilling and innovative approach to curative care • Telemedicine • Career progression and specialised training opportunity coupled with enhanced incentives for providers serving in hard-to-reach areas, with rotation policy • Way forward for ASHAs ? • Define progressive quality standards for different service delivery levels, with flexibility in approach for hard-to-reach areas

26. THANK YOU