Ministry of Health & Family Welfare NRHM Common Review Mission - 3

1. Ministry of Health & Family WelfareNRHMCommon Review Mission - 3 Key Findings: Uttar Pradesh Districts visited: Allahabad, Kanpur City

2. Facilities visited

5. Infrastructure RHS vs PIP Population: 166 million (Census 2001) 196 million (Est 2009-10)

6. 2. Human Resources (HR)(per 10,000 pop’n)

7. 2. Health Infrastructure – RHS 2008

8. 2. Training Load – simple arithmetic

9. 2. Allocation of Funds – Training (excl ASHA)

10. 2. HR Training options Short-term • Contract ANMs from other states • Purchase ANM seats in training schools from other states • Strenghten ANM Training schools (PPP as an additional option) • Deploy AYUSH MOs in vacant positions Medium Term • Start new ANM training schools • Encourage the non-public sector to start ANM training – on a large scale • Preferential seats for ASHAs

11. 2. HR Issues & Options • IPHS implies more new posts required • Major HR review, rationalization and reform is urgently required including multi-skilling • All tiers: Specialists, MOs, Paramedics, ANMs • Substantially increase numbers sent for multiskilling • Expand number of nurse training schools (include PPP)

12. 2. HR Issues & Options • ANMs need refresher courses to manage the increased workload (basic skills missing) • regular mentoring at the PHC/CHC monthly mtgs. • Introduce Public Health and Health Management training as well as positions to ’free up’ specialists for clinical care • Strengthen regular technical supervision and monitoring – use DPMUs

13. 3. Assessment of the case load being handled by the Public System

14. 5. Outreach activities of Sub-centre • Shortage of ANM limits possibility of outreach services • VHND’s conducted - emphasis on immunization • Limited educational input; ANM does very little preparation for IEC activities. • ASHA plays important role for organizing VHND • VHSCs need sensitisation and strengthening on their role

15. 6. Utilisation of untied fund • Health Mela expenses met from RKS funds • likely to deplete RKS kitty • Majority funds of RKS (70% to 80%) used for POL for generators & ambulances • Untied Fund at VHSCs used for • purchase of bleaching powder, cleaning sewage, construction and covering of drains, referral of pregnant mothers • Could be used for purchase of weighing machines, video/audio tape-recorders for IEC etc.

16. 7. Thrust on difficult areas and vulnerable social groups • Availability of ASHA has improved access for vulnerable groups • No special plan or budget for vulnerable or tribal groups in PIP 2009-10

17. 8. Quality of services • Where staff and equipment is available the services appear of good quality • Stay for more than 24 hrs after delivery seen at District Hospital only • MTP services not seen • Use of partograph not seen although training had been given • Cleanliness generally improved • Waste Management (segregation and collection) was functioning at district and some CHCs • Timely payment for sustainability

18. 8. Quality of services cont. • District Hospital Female in Allahabad ISO 9000 certified! • Make it more functional • Paediatrician, Anaesthetist, Ultrasound etc • Showcase to other DHs, CHCs • Consider direct funding and/or special allocation to institutions of excellence to ensure quality is maintained

19. 9. Diagnostics • Routine tests (Hb, TLC, DLC, BS, MP, and Urine) performed at PHCs • Shortage of reagents in Allahabad. • User charges well advertised. • Investigations free for BPL Families • X-RAY facilities were available at some CHCs but radiographer/x-ray technician has to manage • X-ray machine not functioning in Allahabad

20. 10. Logistics & Supply Chain Management • State level procurement outsourced to UNOPS, State Corp. • Medicines generally available • Quota based to shift to demand based • One HSC was lacking essential supplies • State may introduce system to monitor stock flows and stock outs.

21. 11. Decentralized Planning;12. Local Health Action Plan • Though District PIPs (IDHAP) prepared, fund allocation was normative from the State level • Demotivates planning process • IDHAP to be local & evidence based and prioritise activities – fund allocation can be based on local need, priorities and track record • Limited capacity for planning at decentral level • Local health action plans were not visible during field visits • RKS accounts being maintained • Low user charges – mainly OPD & path tests • Largely used for cleanliness and upkeep • Regional Diagnostic Centre (TB Sapru, Allahabad) claimed monthly income of Rs 3 lakhs – used for general maintenance (which was excellent), X-ray plates etc

22. 13. Community Processes under NRHM • Community process initiated through ASHAs, RKS are functional, involvement of VHSC can be further strengthened • Meetings of RKS need to involve Village Pradhan more frequently • Improve sensitisation of PRIs on NRHM • Training module already available - developed by SIHFW

23. 14 ASHA • ASHAs • Highly visible, motivated and effective • Have substantially increased the awareness of service availability at community level • Clearly creating demand for both RCH and NDCP services – especially institutional deliveries • Generally satisfied with their job, payments on time • Most have received two training modules – no refresher training • Plan for attrition and corresponding trainings

24. ASHA cont. To ensure sustainability of the valuable services provided by ASHA: • Establish/strengthen ASHA mentoring • Ensure regular refresher training • Provide career path for well performing ASHAs • preference for entry into ANM training • special pre-ANM catch up courses • ensure placement in local area

25. 15. National Disease Control Programs • NDCPs implemented as special programs • Field evidence: • Divide between NRHM/RCH and NDCPs reducing • Field staff are increasingly aware of and sharing resources across programs • ASHAs involved with RCH and NDCPs (enhancement of compensation)

26. 16. RCH services • Substantial increase in institutional delivery • The increase in deliveries at HSCs underlines the urgent need for second ANM across the state • Women stay up to 24 hours at district level only • Limited availability of FRU services (blood supply issues) • 24x7 facilities functional for normal deliveries – stay is an issue

27. 16. RCH services cont. • Increased demand for RCH services has underlined the need to address issues of • emergency transport, • mobile vans • help-line service – for both providers and users of services • RCH gains from introduction of ASHAs may not be sustained if the recruitment & placement of 2nd ANM is not addressed urgently

28. 17. Preventive and promotive health aspects • Health promotion is limited to ASHA’s providing advice relating to MCH services • State’s health promotion strategy not visible in the districts visited. • IEC material not found. • Health Mela’s to be seen as • opportunities for educating people • promoting health care • providing secondary care

29. 18. Nutrition • Malnutrition including anaemia still a major challenge – especially for delivery! • ASHAs instrumental but nutritional intervention limited to: • Initiation of early breast feeding (within first hour in cases of institutional deliveries) • Exclusive breast feeding for first six month • IFA tablets for pregnant women

30. Nutrition cont. • ASHAs and even ANMs have little knowledge on other nutritional issues • Growth monitoring • Nutrition education • Introduction of weaning food • Introduction of solid/semi solids • Regular weighing of children • Adolescent and pregnant women • ANC Checkups • BP, Weight, HB, Urine tests

31. 19. Non-governmental partnerships • “Saubhagyawati Scheme” • 9 private nursing homes identified for referral of complicated cases for safe delivery • 450 women benefited • NGO involvement • Needs to be revived • MNGO scheme to be revitalised • PPP/NGO involvement to be fast-tracked • Fill HR and infrastructure gaps – contract in/out. • Capacity building – for ANMs, Nurses, Paramedicals etc • Strengthening community involvement • Facilitating monitoring processes and social audits

32. 20. Overall Programme management • SPMU, DPMU and Divisional PMUs in place – big step forward • Institutionalize integration of PMU with Directorate/ CMO activities • Preparation of district plan • Target setting and monitoring • Regular Mobility required • Streamline HR policies for PMU • TA/DA, appraisal, increments, HRA, Leaves • Block level team yet to be constituted.

33. 21. Financial management Significant improvement in the financial mgmt • Timely reporting – both FMRs and Audit Report, • Timely fund transfer from State to districts • Proper record keeping, all payments by cheque, • Improved utilization, Concurrent audit systems in place • Regular monthly meetings held with all DAMs

34. Financial Management cont. • At Block and Below: • Reports not flowing from the Sub-centres and VHSCs  reduced expenditure reporting • Multiple bank accounts at blocks • reports not flowing from the books. • Accounts required to be prepared at block level as all vouchers stay there. • HAs prepare registers without knowledge of finance and accounts guidelines. • Need for a block accountant with knowledge of Tally

35. Financial Management cont. • Stagnant/Decreasing State Budget support especially at sub-district level. • Health mela funds being used from RKS • Need to open bank account at new PHCs and additional PHCs – at least where MO is posted. • Concurrent audit systems not being utilized effectively

36. 22. Data Management • Data uploading on HMIS Portal good • FMRs uploading needs to be improved • Institutionalise checking & validation of data • Block, District, State Review meetings be based on data reported on HMIS • PMU to present analytical reports & key findings to concerned DHS/CMO/BMO etc • Hasten Block level data capturing/training • Use HMIS and DLHS data in IDHAP

37. Innovations • IEC: JSY protsahan rashi cheque with NRHM logo and 3 messages at the back: • Breastfeeding for 6 months • 6 immunizations • Spacing of 3 years for 2nd child • SMS being used by DAM in Kanpur for sending the messages for fund transfer and its utilization. • Clear area demarcation of houses in the villages for ASHA. • Booklet for payment of incentives to ASHAs under 19 heads

38. Key Recommendations • Human Resources & Infratructure • Bold & dynamic strategy with time lines • Help-line for health providers/public • Identify Nodal Facilities at Block level and fully opertionalise them as 24x7 – doctor, nurses, electricty • Deploy Block Team • Improve referral transport • Faster Fund flows to Block and below • coordinate between Main Bank and Lead Bank

39. Key Recommendations • Monitoring – get a grip on critical numerators • ANC, Immunisation, Deliveries, FP, Deaths ... • Improve IEC • Education of girl child – incentivise • Raising age at marriage • Longer stay at institution post delivery (>24 hrs) • Family Planning – small family norm • Regular meetings of State Health Mission • approve plans, • ensure convergence • Secure political support and leadership

40. Views of State Govt • Merge routine immunization with Pulse Polio • Incentivising immunization coverage • Keen to adopt the 2001 Census Population norms for rural health infrastructure. • Restructuring State HR Policy for deployment of doctors and incentives. • Re-deployment policy aims to link doctors to functionality of the Institutions.

41. Views of State Govt .. (cont’d) • Preparing case to increase Nurses. • Operationalise MMUs to increase the reach and penetration of health services in the rural areas. • Initiate steps to improve sensitisation of MOs and ANMs on NRHM interventions and involve MOs in clinical activities. • Information on availability of stock and flow of drugs to the Districts on internet. • Low allocation of budget for the health sector • Implementation of 6th CPC recommendations.