Workshop on Quality, Equity & Accountability National Rural Health Mission Madhya Pradesh

1. Workshop on Quality, Equity & Accountability National Rural Health Mission Madhya Pradesh 6 September 2009 Bhubaneshwar

2. What good does it serve to treat people’s illnesses and…………… send them right back to the conditions which made them sick in the first place

3. Why Health Equity? • ………………..Poor health is not confined to those worst off. In countries at all levels of income, health and illness follow a social gradient: the lower the socio-economic position, the worse the health……It doesn’t have to be this way and it isn’t right that should be like this. Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair…….Putting right these inequities, between and within countries-is a matter of social justice…….an ethical imperative……….Social injustice is killing people on a grand scale………………..

4. Some Definitions: • “Inequities are differences in health that are unnecessary, avoidable, unfair and unjust.”– Margaret Whitehead • “Equal opportunity of use of health services for equal need” – Newbrander and Collins

5. NRHM provides the oppurtunity: • Exercising Principle of Subsidiarity • Putting Money where the mouth is: • Financing Innovations • Evaluations in the most challenging locales

6. Service Provision Challenges in Madhya Pradesh • Distance: 3.3kms/health worker • Road penetration of MP: 52/100 km2 Vs All India Av 75/100 km2 • Scarcity of Qualified HR • Infrastructure (Bed strength has been increased by 8000) since launch of NRHM • Tribal Areas • Data Dissagregation • Planning Capacity at district and sub-district level • Convergence with determinant departments • Lack of Awareness-Real Access Barrier

7. Though GoMP has initaited specialised programmes for specific vulnerable groups, we do not believe in: Categories of Inequity Creating competition between the vulnerable Gate-keeping criteria which results in exclusion

8. GoMP responses: • Deen Dayal Mobile Health Clinic: 91 blocks (all tribal blocks) • Package of services • Malaria Diagnostics • Sputum test for TB • Health IEC • 27 difficult blocks had no response to tenders • Janani Express: Emergency Transport: 298/313 blocks running in all 50 districts • Referral Transport for pregnant women • Referral Transport for malnourished children

9. GoMP responses continued… • Deen Dayal Antyodaya Upchaar Yojana: Family Health Benefit Scheme to the cap of Rs 20,000/familyfor indoor treatment: • Reducing Out of pocket expenditure • Cross-subsidizing diagnostics’ • State Illness Assistance Fund: • Free medical treatment for 13 major illnesses requiring surgical procedures • Hospitalisation to the cap of Rs 150,000

10. GoMP responses contd….. • Data disagregation of JSY beneficiaries initiated: SC/ST and BPL • State PIP and DHAP planning has centre-staged equity into the planning (facilitation guidelines formalised) • ANMTCs’ capacity and graduates increased • HR deployment in difficult areas: Building consensus on definition

11. GoMP responses: • TAST supported composite revised health index • Weighted Composite of HDI + JSK + Sex ratio + Tribal and SC population + Malnutrition prevalence + Population density • 10 most marginalized districts identified for focused action to strengthen the systems • 10/30 CEmONCs and 76/94 BEmONCs functional.

12. Mapping of Districts as per Selected parameters

13. Districts with High Weightage Scale Districts with Low Weightage Scale District in relation to different parameters B H D M R N G L R D T A S O P Shivpuri Tikamgarh Chattarpur R W A Neemuch A K N G U N Panna S T N Sidhi M D S S J P S A G V D S R J G D M H S D L K T N Umaria R T M Bhopal Ujjain J B P R S N Dindori S heopur A N P N S P Indore Jhabua M D L Hosangabad D H R D W S S N I H R D C D W K N D B L G K R G Barwani B T L B H P

14. Accessibility Challenge - Janani Express Yojana 2006-07 2008-09 Only in 10 Districts

15. CHALLENGES • Acute Malnutrition prevalence • Domestic Violence Prevalence rates 45.8/37.2 • Lack of convergence amongst determinant departments • Inadequate water sanitation coverage esp sanitation • Citizens’ Engagement in the Sector

16. 150 NRCs – 2000 Beds – 40,000 SAM children Treated NRC – Institution for Management of SAM children No. of children cured in NRCs

17. Malnourished Children Treated at NRCs

18. SNCU Sick babies being treated at SNCU 20 bedded level II Unit at 13 districts hospital

19. Sick New Born Care Units ST Dominated B H D SC Dominated M R N General G L R D T A S O P S V P T K M R W A C T P N M C A K N G U N P A N S T N G S D H M D S S J P S A V D S R J G D M H U M R S D L K T N R T M B P L U J N J B P R S N S H E A N P N S P D D R I D R J B A M D L D H R D W S H S B S N I H R D C D W K N D B L G K R G B R W B T L B H P

20. Way Forward • Convergence of Grassroots Committees: Swastha Gram Samiti with the mandate of health and health-determinants issues • Investing in their capacity building for informed engagement: 10,60,000 absolute number of trainees • Nutrition Rehabilitation Centres: • Convergence of Health and Nutrition line Depts and frontline workers • Monetization of access costs to encourage uptake • Enabling System Responsiveness: Taking grievance redressal to district and sub-district levels • Service Provider Attitude: Encouraging Empathy in the rubric of Medical Ethics

21. Public Policy is an inexact science • Citizens engagement in the sector • Community Monitoring • Greivance redressal at district/sub-district levels • Chronology of opening the sector: Tendering & contract management capacity • Reclaiming RKS for patient welfare • Billing & Outcomes’ transparency • Communicating health entitlements • Service Provider empathy: Not from morality grounds but from treatment efficiency & litigation loads’ issues • Evaluation of schemes in the most challenging locales

22. Thank You