NRHM – Making a Difference Everywhere in partnership with States/UTs

1. NRHM – Making a Difference Everywhere in partnership with States/UTs Decentralizing thought and action Starting from the problem

2. Public Policy -Getting basics right • Theory without practice is as dangerous as practice without theory • Begin from the problem; do not impose a solution without looking at the problem. • I don’t care what colour is the cat, as long as it catches mice – pragmatic, evidence based, not ideological!!! • The map is not the territory!!! • Samakhya – Dialogue of equals !!! • If you do not do what you have to do, you will never be able to do what you want to do !!!!

3. NRHM – What is different……… • A true partnership with States. • Space for innovations – do what works. • Distrust to trust – decisions at facility level. • Community institutions/monitoring as focus. • A worker, an institution and an event in every village – ASHA, VH&SC, VHND. • Public health focus – addressing local specific mortality and morbidity. • Building capacities for local action. • Recognizing the need for management skills.

4. 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

5. NRHM - Feedback from the Field • SRS data from Census of India - IMR/MMR/TFR/Birth Rate/Death Rate. • District Level Household Survey – III 2007-08. • Qualitative Findings of Common Review Mission December 2008. • Internal Monitoring Reports on Physical and Financial Progress – April – June 2009. • Performance Audit of CAG - 2008.

6. Validation by SRS Maternal Mortality Ratio • Maternal Mortality Rate is down from 301 per 100,000 live births (2001-03) to 254 (2004-06) based on the official estimates of Registrar General of India(RGI).

7. MMR – Performance of States • MMR over 400 – UP ( 440), Assam(480) • MMR 300-400 – Bihar, MP, Rajasthan, Orissa • MMR 200-300 - Karnataka • MMR 100-200 – Andhra Pradesh, Tamil Nadu, West Bengal, Gujarat, Haryana, Punjab, Maharashtra • MMR below 100 - Kerala

8. Validation by SRS Infant Mortality Rate • IMR is down from 58 per 1,000 live births (2005) to 53 (2008). Possible to achieve the required reduction of 4-5 points a year to reach 30 by 2012, if neonatal mortality is effectively addressed through 48 hour stay after institutional delivery. Thrust on nutrition needed.

9. Validation by SRS • TOTAL FERTILITY RATE • Down to 2.7 in 2007 • 14 State/UTs at or below Replacement level • 7 States/UTs between 2.2 and 2.6 • UP, Bihar, Rajasthan, MP, Jharkhand, Chhattisgarh, and Assam among major States have very high TFR 2.7 – 3.9.

10. Validation by DLHS of a few indicators INSTITUTIONAL DELIVERY • Institutional deliveries have increased from 40.9% (2002-04) to 47% (2007-08). • Most significant increases in hitherto low performing States – MP (66.4%), Rajasthan (50.2%, Bihar ( 47.3%), Orissa ( 43.8%). • JSY demand side financing ( conditional cash transfer)strategy is working. • Quality of service will need continuous attention.

11. Validation by DLHS of a few indicators IMMUNIZATION • Full immunization coverage of children upto 2 years has gone up from 45.9% (2002-04) to 54.1% (2007-08). • Most significant increases in hitherto under covered areas – Bihar (20.7% to 41.4%), Jharkhand (25.7% to 54.1%), Rajasthan (23.9% to 48.8%), Orissa ( 53.5% to 62.4%), Madhya Pradesh( 30.1% to 36.1%)

12. NRHM – What is the impact

13. NRHM-OTHER IMPROVEMENTS • KEY FINDINGS OF DLHS-III 2007-08 • 53.1% PHCs working on 24 hour basis • 90.1% CHCs having 24 hour normal delivery services. • 90.6% Sub Centres with ANMs. • 19.2% PHCs with AYUSH doctors. • 90.7% villages having JSY beneficiary. • Full Immunization up to 54.1% • Institutional deliveries up to 47%.

14. NRHM –Gains to health system • Human resources – 7 lakh ASHAs and one lakh health workers under NRHM. • Physical infrastructure – 30% Sub Centre buildings, 20% PHCs, 75% CHCs, 75% District Hospitals being constructed/up graded • Untied grants to all public institutions. • 1125 Mobile Medical Units across the country. • Over 10 States have Emergency medical system – others with more ambulances. • Doctors, drugs and diagnostics – improvement. • Public expenditure on health up from 1.19% in 2004-05 to 1.41% in 2008-09 ( Economic Survey).

15. NRHM – Institutional strengthening • VHSc, PRIs, RKSs, DHMs, SHMs, MSG. • Joint Bank Accounts for VHSC and Sub Centres. • Registered RogiKalyanSamitis at PHC and above – legal entity – insurance, etc. • Flexibility and adequacy of funding with accountability framework to ensure public action. • Decentralized planning and implementation • States, districts, blocks, villages deciding priority for public health action. • System for procurement and logistics – TNMSC. • Improving Human Resource Management.

16. NRHM – System strengthening • Financial Management – FMR • Programme Management – SPMU, DPMU • Data Management - HMIS • Development of Standards – IPHS • Capacity development for public health – public health management master’s (PHFI) and diploma (PHRN – IGNOU). • Family Medicine programme – CMC Vellore • Professional Development Courses – NIHFW, SIHFWs • Accountability system – Concurrent Evaluation, Community Monitoring, Performance Audit of CAG.

17. NRHM – Infrastructure Initiatives

18. NRHM – Fostering Innovations • Decentralizing thought and action. • Respecting local thought and action. • Providing platform for sharing and learning. • Intensive engagement in capacity development at all levels. • Building systems that fosters innovations. • Analytical feedback to States. • Crafting convergent and credible platforms at all levels of care. • PUTTING PEOPLE’S HEALTH IN PEOPLE’S HANDS – TAKING CHARGE!!!!

19. NRHM – Time line for Activities as per Framework for Implementation 7/2006 Where we stand in October 2009

20. FULLY TRAINED ASHAs The Target Substantially achieved. 7.30 lakh ASHAs selected. 5.25 lakh completed up to 4th module 4.67 lakh have drug kits ASHA training lagging in Bihar ASHAs found very active in all studies – linking households to health facilities. • Fully trained ASHA for every 1000 population/large isolated habitations. • 50% by 2007 • 100% by 2008

21. VHSC in every revenue village The Target Substantially achieved 4.27 lakh Village Health and Sanitation Committees already constituted. Funds released for all VH&SCs – VHNDs regular. Bihar and West Bengal lagging behind. Process required amendments in Panchayat Acts and is time intensive. • Village Health and Sanitation Committee constituted in over 6 lakh villages and untied grants provided to them. • 30% by 2007 • 100% by 2008

22. Sub Centre and service guarantees The target Functionally achieved. 2nd ANM will take time. DLHS-III found 90.6% Sub Centres had ANM 19.8% had additional ANM. 44,429 ANMs on contract under NRHM 38,832 out of 1.46 lakh Sub Centres have 2nd ANM ( 26.6%). States to give Male Worker. 1.5 Crore Village Health and Nutrition Days organized. ANM Schools revived and capacity enhanced – will take a little while to get numbers. • 2 ANM Sub Centres strengthened to provide service guarantees as per IPHS • 30% by 2007 • 60% by 2009 • 100% by 2010

23. PHC and service guarantee The target Functionally achieved. HR/Quality will take time. DLHS-III found 53.1% PHCs working 24X7, 19.2% had AYUSH Doctor, 24.3% hadLady Medical Officer. 7613 PHCs out of 23458 PHCs are 24X7 and 5520 have 3 Staff Nurses. Doctors, Paramedics, Lab Technicians, Nurses added in large numbers. 38.5% PHCs conducted more than 10 deliveries in previous month(DLHS-III). • PHCs strengthened with 3 Staff Nurses to provide service guarantees as per IPHS • 30% by 2007 • 60% by 2009 • 100% by 2010

24. CHC and service guarantee The target Functionally achieved HR/Quality will take time DLHS-III found 90.1% CHCs have 24 hour normal delivery services, 65.6% have functional OTs, 52% CHCs are designated as FRUs but only 9.2% have blood storage facility. 3606 CHCs out of 4276 functioning 24X7. Large scale physical infrastructure, human resources and equipment provision under NRHM. • CHCs strengthened with 7 Specialists and 9 Staff Nurses to provide service guarantees as per IPHS • 30% by 2007 • 50% by 2009 • 100% by 2010

25. SDHs and service guarantee The Target Functionally achieved HR/Quality will take time 1664 such facilities functioning 24X7 and 1294 had at least 3 Staff Nurses. 577 SDHs working as FRUs. Physical up-gradation and human resource provision made in most States. • 1800 Sub Divisional Hospitals strengthened to provide quality services. • 30% by 2007 • 100% by 2010

26. DHs and service guarantee The target Functionally achieved HR/Quality will take time. 508 District Hospitals are now FRUs. Physical Up – gradation, human resource provision and equipments in a large number of DHs. 438 DHs have taken up up-gradation under NRHM. • 600 District Hospitals strengthened to provide service guarantees • 30% by 2007 • 60% by 2009 • 100% by 2010

27. RKSs in all facilities The Target Substantially achieved Pace of utilization uneven. Over 95% District Hospitals and CHCs already have registered RogiKalyanSamitis with regular flow of funds. Nearly two thirds of PHCs have established RKSs and funds are flowing to them. Has contributed significantly to local level leadership and decision making process. • Rogi Kalyan Samitis/ Hospital Development Committees established in all CHCs/SDHs/DHs. • 50% by 2007 • 100% by 2009

28. District Health Action Plan The Target Substantially achieved Planning process will need nurturing 603 of the 638 districts have prepared District Health Action Plans. Many have moved towards village and Gram Panchayat Plans. Regular training through PHRN for decentralized planning. • District Health Action Plan 2005-2012 prepared by each district of the country • 50% by 2007 • 100% by 2008

29. Untied grants to all institutions The Target Achieved Rate of expenditure has picked up United grants provided to all institutions in the government sector across the country. Put to very good use in a large number of facilities. Utilization is still slow in some states for fear of audit – local level personnel have lost the confidence to spend untied funds over the years. • Untied grants provided to each VHSC, Sub Centre, PHC, CHC to promote local health action • 50% by 2007 • 100% by 2008

30. Maintenance grants to all The Target Achieved Rate of expenditure has picked up. Being provided to all institutions across the country that have their own buildings. Making a difference in the physical environment of a large number of facilities. • Annual maintenance grant provided to every Sub Centre, PHC, CHC and support to RKSs at Sub Division/District Hospital • 50% by 2007 • 100% by 2008

31. Society with Management skills The Target Substantially achieved 34 out of 35 States/Uts have SPMUs. 617 out of 638 districts have DPMUs in place. 2754 Block Managers in place Programme Managers, Finance and Accounts Managers and Data Managers making a difference. • State and District Health Society established and fully functional with requisite management skills. • 50% by 2007 • 100% by 2008

32. Community monitoring The Target Useful pilot phase States trying diverse models AGCA supported Community Monitoring pilot in 9 States by NGOs. Public Hearing and constitution of Village Health Committees to improve accountability. PRIs involved in monitoring. Committees set up in many States. • Systems of community monitoring put in place. • 50% by 2007 • 100% by 2008

33. Procurement & Logistics streamlined The Target Reform process has begun; few successes; many more in pipeline. Procurement audit by professionals completed in 5 States. Kerala Corporation on the pattern of TN fully functional. WB Corp. constituted. Haryana, Bihar, Orissa, Chhatisgarh, Gujarat, AP, Karnataka carrying out reforms. Task Force under ShriPoornalingam (TNMSC) to facilitate process. PROMIS launched for computerized inventory management. Central Procurement Agency under active consideration. • Procurement and logistics streamlined to ensure availability of drugs and medicines at Sub Centres, PHCs/CHCs. • 50% by 2007 • 100% by 2008

34. Intra health sector convergence The target Substantially achieved. Breaking vertical silos takes time. Significant efforts to bring intra health sector convergence through the planning and appraisal process with States. All such needs reflected in PIPs. • SHCs/PHCs/CHCs/SDHs/DHs fully equipped to develop intra health sector convergence and coordination • 30% by 2007 • 60% by 2008 • 100% by 2009

35. Inter sectoral convergence The target Significantly achieved. Common platform for convergence PIPs have an inter sectoral convergence chapter. Many initiatives in many States. VHSC and VHND for convergence. Committee at national level for directions and advisories to States through joint letters. • District Health Plan reflects convergence with wider determinants of health like drinking water, sanitation, women’s empowerment, child development, etc.

36. Facility and household surveys The Target DLHS-III District Reports – immensely useful DLHS-II, carried out in 2007-08. Detailed district reports for nearly all the districts available in the public domain on the Ministry’s website. Provides very useful data for planning and analysis. Based on household and facility surveys. • Facility and Household surveys carried out in each and every district of the country. • 50% by 2007 • 100% by 2008

37. Annual Public Report on Health The Target DLHS-III Reports are forthright in their assessment DLHS-III ( 2007-08) has already published District Health Reports for over 90% of the districts and material is in public domain. Concurrent evaluation by independent research agencies completed in 200 districts – reports by November 2009. • Annual State and District Public Report on Health published. • 30% by 2008 • 60% by 2009 • 100% by 2010

38. Institution wise performance The Target HMIS District Web Based system functional Facility Reports over next three months. District Concurrent evaluation will provide findings on service guarantees. Web based District HMIS already launched and operational. It will provide facility specific performance data over the next three months. • Institution-wise assessment of performance against assured service guarantees carried out.

39. Mobile Medical Units in districts The Target Achieved in difficult districts. Many districts may not need. 310 district have operational MMUs. Many district have a large number of MMUs depending on the need. Thrust on hard to reach areas. Diversity of MMU models. • Mobile Medical Units provided to each district of the country. • 30% by 2007. • 60% by 2008. • 100% by 2009.

40. Road Ahead: Policy Issues for the Consideration of States

41. I – COMMUNITISATION While Institutions for community ownership have been established, large scale development of capacity is needed for effective communitisation of Public Health services Transparency and accountability built into institutional arrangements – need for full public disclosure of all programme interventions

42. II – MEDICAL EDUCATION A few District Hospitals in high focus States must have a road map to become Medical Colleges – reforms in MCI needed to facilitate such a process without compromising excellence New courses aimed exclusively at in-service public sector needs: One year Public Health Management Diploma through PHFI, 2 year Distance Family Medicine Programme through CMC, Vellore, more DNB in Family Medicine in District Hospitals etc. proposed Need for accelerating multi-skilling as a general policy but immediately for gynecologists and anesthetists State experiments in three year programme of Rural Medical Assistants and Rural Health Practitioners in Chhattisgarh and Assam- need evaluation and follow up

43. III – NURSING EDUCATION Priority attention to improve and enhance in-take in all existing Government Nursing Institutions New Nursing Schools and Colleges in deficient States with partnerships in faculty from surplus States Partnerships with non-governmental sector for Nursing courses Reservation of seats for ASHAs and Aanganwadi workers based on local criteria in ANM/Nursing Schools

44. IV – PROCUREMENT AND LOGISTICS Effective and efficient public system of health care needs transparent, timely and quality procurement and logistic systems TNMSC – an exemplar Jan Aushadhi programme for promotion of generic drugs and for essential drug lists Need for corporations in States to manage infrastructure, drugs and equipment Need for a transparency act like in Tamil Nadu.

45. V – HUMAN RESOURCE MANAGEMENT REFORMS New cadre rules that allow Specialists for Block Hospitals Incentives for difficult areas and performance linked incentives Continuing Medical and Nursing Education targeted at all cutting edge health functionaries Restructuring Directorates to lead more effectively towards delivery of quality services Move in direction suggested by Draft Task Force report on Human Resource Management shared at Puducherry workshop

46. VI – GOVERNANCE REFORMS Even greater thrust on transparency, accountability and full public disclosure Reforms in cadre management, transfer and posting policies, and in higher compensation for difficult areas Shift in focus from employment guarantee to service guarantee

47. 100 Days Agenda for NRHM Identification of difficult, most difficult and Inaccessible areas particularly in Hilly, NE and Tribal areas for extra incentives ( if not done already). HMIS in public domain. Thrust on home and facility care for new born children and for safe deliveries in remote areas.