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 1

2. Facilities visited 2

3. 3

4. 4

5. Infrastructure RHS vs PIP 5

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

7. 2. Health Infrastructure – RHS 2008 7

8. 2. Training Load – simple arithmetic 8

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

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 10

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) 11

12. 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 12 2. HR Issues & Options 

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

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 14

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. 15

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 16

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 17

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 18

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 19

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. 20

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 21

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 22

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 23

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) 25

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 26

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 27

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 28

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 29

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 31

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. 32

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 33

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 36

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 38

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 39

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. 40

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. 41