3 rd Common Review Mission (CRM) under NRHM in Rajasthan

1. 3rd Common Review Mission (CRM) under NRHM in Rajasthan (November 4-9, 2009) Districts: Alwar and Bhilwara Team: Dr. C. Anbazhagan (Sr. Regional Director, Bangalore) Dr. Ritu Priya (Advisor-Public Health Planning, NHSRC) Dr. Sanjay Dixit (Professor-Dept. of Community Medicine, Indore) Dr. Loveleen Johri (Sr. Advisor-RH, USAID) Gautam Chakraborty (Sr. Consultant-Health Care Financing, NHSRC)

2. Progress against Target & Outcomes

3. Major Innovations in Rajasthan 1. Mukhya Mantri (BPL) Jeevan Raksha Kosh Cashless service to BPL patients in govt. hospitals (all medicines and consumables included, which if not available in govt. supply, is procured from market and made available to BP patients for free) No Insurace Co. or TPA involved, so no service charges paid Incremental cost of additional supplies & consumables covered, so cost per patient low as compared to payment against “prices” to hospitals under insurance schemes All health conditions covered with limit/cap to the cost per case In-house software to track prescriptions /treatments and costs of each BPL patient by hospital

4. Major Innovations in Rajasthan continued… 2. Jan Aushadhalaya Medicine counters in public hospitals running on 24x7 basis under RMRS Medicines/supplies provided at below the market rates Procurement for such stores directly from PSUs, bypassing the dealer/retailer chain, thus obtaining medicines at very low cost Being scaled-up, based on the Chittaurgarh model of Jan Aushadhalayas

5. Major Innovations in Rajasthancontinued… 3. Pregnancy & Child Tracking System (PCTS) Tracking of Pregnant Mothers (for ANC) and Children upto one-year old (for Immunisation), by name Software developed in-house Currently conversion of beneficiaries’ database (from family registers) to electronic form, is underway. Based on Pregnancy Tracking System (PTS) piloted in Dungarpur district

6. Major Innovations in Rajasthancontinued… 4. Rural Health Services Scheme (RHS) Appointment of Doctors and Paramedics through Rajasthan State Public Service Commission (RPSC), specifically for rural health facilities. The cadre to be rotated only in designated rural areas 4. YASHODA scheme Volunteeres placed in govt. hospitals to counsel mothers on breast-feeding and other neo-natal care issues

7. Observations of 3rd CRM in Rajasthan 1. Infrastructure 4% shortfall in Sub Centres, 9% shortfall in PHCs and 23% shortfall in CHCs 15% Sub Centres and 2% PHCs without buildings 2. Human Resources At district level NRHM has provided bulk of the nursing (Staff Nurse, PHN, ANM) staff (in Alwar 34% of such staff is under NRHM) Shortage of Specialists, MOs, Nurses and ANMs Training Capacity (in terms of Infrastructure and Quality of Training) needs improvement

8. Observations of 3rd CRM in Rajasthan continued… 3. Public Health Facilities Increase (from 2005 to 2008) in delivery cases across PHC/CHC and fall in normal delivery cases in DH (in Alwar normal deliveries increased by 50% in PHC, more than 100% in CHC and fell by 50% in DH). Fall in delivery related complications at FRUs, but increase in such cases at DH (in Alwar fall at FRU is almost 100%, whereas at DH there is almost 200% increase) FBNCs working well at DH level Complicated delivery cases still referred out of FRUs (almost 90% cases referred out in Alwar, i.e. not managed at the FRU level) Fall in OPD cases in PHCs (in Alwar) and DH (in Bhilawara) Satellite Hospitals need more strengthening to share the load of medical College hospitals

9. Observations of 3rd CRM in Rajasthan continued… 4. Outreach Services 97% Sub Centres have at least 1-ANM and 17% have 2 ANM/GNM GNM, being trained in clinical services and not in outreach services, cannot replace ANM ANM clinical skills need strengthening 5. Difficult Areas & Vulnerable Groups MMUs being purchased 1-per-Block Urban RCH Centres under PPP mode for slum population MMJRK for BPL population Mapping of uncovered pockets needed for focussed coverage

10. Observations of 3rd CRM in Rajasthan continued… 6. Logistics & Supply Chain Management More than 50% items from stock registers found out-of-stock across PHCs/CHCs. Stock-outs lasting 6-months or more. Inventory Management training needed for storekeepers 7. Community Processes Nutrition is still not very prominent in MCHN Days VHSCs need to be involved more in area specific plans and not merely for filling up CNA-type formats 8. ASHA 95% ASHA-Sahayoginis in place, trained upto 4th module Needs to take on more of “activist” role rather than “health worker” role

11. Observations of 3rd CRM in Rajasthan continued… 9. Disease Control Programmes RNTCP: 12-15% cured cases under DOTS are relapsing as MDR cases within 2 years NVBDCP: API is 0.69, Pv is common and Pf is very low; slides not available in some centres and not sent for back checks 10. RCH Maternal Health: Partographs were not seen; Yashodas need to be involved in PNC and Family Planning counselling; staff need more skills in tackling Obstetric and Neonatal emergencies JSY: JSY has increased no. of deliveries, payments are happening by-and-large in time

12. Observations of 3rd CRM in Rajasthan continued… 10. RCH continued... Child Health: SNCU and FBNC operational in the state; Malnutrition Treatment centres may be renamed as Rehabilitation Centres to focus on “rehabilitation” rather than “treatment” Family Planning: lacking focus, especially on IUCD; IEC/BCC was found inadequate; staff need more skill upgradation 11. Nutrition ICDS registers show very low no. of Grade-III/IV children, whereas surveys like DLHS show 33-40% malnutrition among children Referral of sock malnourished children to MTC needs to improve VHSCs may be involved in identification and rehabilitation of malnourished children

13. Observations of 3rd CRM in Rajasthan continued… 12. Non Government partnerships Involvement of NGOs is still peripheral to “mainstream” strategies and pure incidental. State is implementing many PPPs including ERS, MMU, Urban-RCH PPPs to be based on more realistic costing and reimbursements, in line with the outputs/outcomes 13. Overall Programme Management Coordination needs to improve between NRHM consultants and regular staff, especially for planning and monitoring High trunover expected in view of dissatisfaction among NRHM staff regarding their career prospects and remuneration

14. Observations of 3rd CRM in Rajasthan continued… 14. Financial Management Since start of NRHM expenditure at SHC/PHC have increased 5-6 times, including funds for ASHA, JSY, mobility, VHNDs (which is 3-5 times the amount of Untied Grants handled by them) The state has already booked 60% of sanctioned PIP (of 2009-10) by Nov’09 Tally software installed upto Block level, although accountants need more orientation At a given point, 20-25% funds lie as advances, of which 30-33% is already spent but awaiting UC/SOE Govt. and NRHM accountants need orientation on NRHM fnancial principles and GF&AR

15. Observations of 3rd CRM in Rajasthan continued… 15. Data Management P&CTS being put in place Redundancy of formats and softwares need to be addressed to remove confusion at district and field level Use of data for monitoring and planning needs to be encouraged further.

16. THANKS