Integration in the Context of Implementing the NRHM Mandate

1. Integration in the Context of Implementing the NRHM Mandate NHSRC & CSMCH-JNU Collaborative Workshop 18th-19th August, 2008 Ritu Priya & T. SundararamanNHSRC

2. In This Presentation: Clarification of Terms : The Working Definitions we are adopting Conceptualisation of the Scope and Potential Space for Integration under NRHM, based on: a) the NRHM Framework, b) analysis of the state PIPs and the discussions on them in the ministry, c) the Common Review Mission reports, and d) observations in the field. Brief analysis of the experience of Integration in the past for lessons and warnings: The NTP, MPW scheme, IVBDCP, ICDS, …… Summarising the Challenges and a tentative proposal for moving towards integration under NRHM.

3. CONVERGENCE IN PUBLIC HEALTH Defining the Terms CONVERGENCE = coming together of services and/or governance structures or activities for a common set of health objectives. INTEGRATION = intra-sectoral convergence, i.e. between various components of the health care system. The convergence could be organisational, administrative, and/or technical. INTER-SECTORAL COORDINATION = functional linkages between the health services and various other sectors that influence health status COMPREHENSIVE HEALTH CARE = promotive, preventive and curative care that addresses health status of populations from ‘womb to tomb’ . Includes health services and other sectoral interventions. Services may or may not be ‘integrated’ at all levels. PUBLIC-PRIVATE-PARTNERSHIPS = Convergence of Public and Private sector services

4. INTEGRATION: INTRA-SYSTEMIC CONVERGENCE • DEFINING THE BOUNDARIES FOR THE HEALTH CARE SYSTEM • Within the public health services (excluding AYUSH) • Within the public health services (including AYUSH) • From home to hospital continuum of care including home remedies and folk practices • Within the whole health services sector: • including all levels of care, from home to hospital, • those of modern medicine and AYUSH, and • public as well as private services

5. ARGUMENTS FOR INTEGRATION • Administrative and Financial Efficiency and Cost-Effectiveness • Community and Patient Friendly as a One-Window Service • Epidemiological Rationality – Multi-causality and social determinants of health, co-morbidities influence outcomes of any specific programme • These considerations should guide setting of boundaries of the system and sub-systems for integration.

6. Private Healthcare Public Healthcare Modern Medicine Modern Medicine AYUSH AYUSH Local Health Traditions The Health Care System

7. INTEGRATION UNDER NRHM NRHM PLAN COMPONENTS Part A: RCH (maternal health + child health + family planning) Part B: NRHM ADDITIONALITIES (Health Service System Strengthening with Flexible funding for local planning, infrastructure, human resources and governance restructuring) Part C: Immunisation Part D: Communicable Disease Control Programmes Part E: Convergence (mainstreaming AYUSH and revitalising local health traditions) as well as inter-sectoral coordination for health

8. Public Health Service Delivery System Tertiary Systems Strengthening [NRHM ‘B’ & ’E’] National Health Programs Secondary [NRHM A, C & D] Primary Level Healthcare Institutional Pyramid Focus of Current Integration Discourse

9. Optional Approaches to Integration Integrate Existing Communicable Disease Control Programmes among themselves – within ‘C’ & ‘D’. Integrate Existing Communicable Disease Control Programmes among themselves and with the Primary Health Care services – ‘C’ & ‘D’ with ‘A’; ‘B’ and ‘E’ to support. Integrated (and Comprehensive) District Health Planning based on local Epidemiological priorities and Health care system context.

10. INTEGRATION UNDER NRHM contd. The spaces that NRHM has provided for integration: • Departments of Health and Family Welfare in the MOHFW merged • Integration of Vertical Disease Control Programmes – State and District Societies merged into one State/District Health Society; A common NRHM budget and the funds used through one common bank account. • Mainstreaming AYUSH – AYUSH practitioner, paramedic and medicines co-located with allopathic services at the PHC and CHC; ANM and ASHA given a few AYUSH medicines, such as for anemia. • Governance Structures – State/District Health Societies, Village Health and Sanitation Committees, Hospital/Facility Planning & Monitoring Committees ; Annual State PIPs / District Health Action Plans; • Public-Private-Partnerships – To improve quality and access to services of the underserved areas /sections.

11. INTEGRATION UNDER NRHM contd. The spaces that NRHM has provided for integration continued: • An integrated HMIS for monitoring various activities • The IPHS and the financial support to reach IPHS standards. Also IPHS and service guarantees. • HR development to meet facility needs as different from meeting • programme needs. • Moves towards integrated skill development and training plans. • Integrated BCC planning. • However each of these spaces are under-utilised and sometimes not utilised or used in a way in which vertical fragmentation is maintained. Documenting how this happens and resisting it is the challenge.

12. Integration between programmes/general health services commonly envisaged in the states as: Sharing of FAX machines, computers, etc. Laboratory services / laboratory technicians be shared Common bank account Common management and monitoring structure - SPMU/DPMU Untied funds to facilities strengthen them and support programmes That is only as a greater form of administrative and financial efficiency. No element of technical/epidemiological rationality, people’s needs and convenience.

13. NRHM as contested terrain…. • Between public provisioning of health services with public financing versus private provisioning with public financing (and public provisioning with part private financing eg user fees)!!! • Between a vertical centralised health programme led approach with systems back up versus decentralised systems-led approach with increasing integration of programmes. • Between a sovereign self-reliant catch up with the world based on the global best in knowledge and a decentralised model of knowledge generation, versus dependence on donors for technical assistance and funds with a vertical model of knowledge diffusion.

14. INTEGRATION UNDER NRHM continued- Two Public Health Paradigms [Diverse Approaches to the Vertical Programmes and General Health Services Interface within the NRHM] The ‘Additionalities’ Approach: Parts ‘B’ and ‘E’ as adjuncts to the vertical programmes The ‘Health Systems Strengthening’ Approach: Part B as major focus of the NRHM.

15. The NRHM Additionality Approach • Parts A, C & D as primary focus: RCH-II, Immunization and Disease control programmes: (Malaria, tuberculosis, Leprosy, HIV) All the above governed by international agreements All the above vertical All of which signed before NRHM All of which dependent on externally funded technical assistance PLUS • Part B: NRHM additionalities, to attend to health systems issues that limit effectiveness of the national health programmes. PLUS: • Health related sectors: very much of a token presence in deference to political sensibilities

16. NRHM – as health systems strengthening approach • NRHM seeks to strengthen state health systems. • Health programmes would increasingly get integrated into it. • Increasingly stand alone programmes would not be necessary as “facilities and outreach programmes” become fully functional, integrated, comprehensive. • Also they would become unnecessary as some of the current priorities are achieved and contribute less to burden of disease eg leprosy, polio… • This would facilitate decentralisation where centre’s role would be limited to defining standards, channelisation of finances and technical resources to prevent uneven/inequitous development. Safeguard equity and quality.

17. Fragmentation within NRHM Initiatives • NRHM setting up its own distinct, vertical administrative structures – Processes for integrating these with the existing structures by 2012 essential • JSY fragmenting maternal health services by– • SBA and institutional deliveries delinked • ignoring community-based maternal services that atleast 20% deliveries will require even by NRHM goals, and in practice many more. • Once the programme/ incentives for institutional deliveries, the most vulnerable will be left with no fall back at all. • Since only 15% are expected to have any complications, subjecting 85% to unnecessary institutionalisation is wasteful and over-medicalising. • Dai huts/sub-centre deliveries with access to good emergency transport and referral services possible under NRHM. • incentive payent to ASHAs creating conflictual situations between the AWW, ANM, ASHA in some states.

18. Contd. Child health initiatives poorly linked to each other. HMIS, NHP data and disease surveillance continue to be isolated from each other. The Block Statistician still handles FP data only!

19. Lessons from Past Experience • The National Tuberculosis Programme of 1962: • classically planned to “sink or sail with the general health system”; • based on a sound evidence base of epidemiological research, • assessment of technology and delivery systems, • patient’s disease related perceptions and treatment seeking behaviour, • operational research. • Its success has been its functioning with horizontal integration at the district and below, its in-built indicator-based monitoring system, and dealing with the suffering of 30-40% of expected cases even with the low level of Public health service functioning. The satisfaction that it did not distort the general health services development.

20. However: • Its drug supply was irregular • social support to the patients for long-term treatment was missing. • Its dependence on the training of medical officers to ensure operationalisation of the well-planned programme lead to its inability to change the dominant mindset, so the programme and its integrated approach got marginalised. • The RNTCP has corrected the first two, but not the dominant technology-oriented mindset. Thereby TB treatment of the majority is in the enlarging private sector and remains irrational.

21. NTP contd. • Negative Lessons: • Supplies and logistics are important operational issues • Social support is important in longterm treatment • Providers’ perspectives are important in implementation and have to be factored into any planning process. • An institutional support and technical base as strong as the NTI and TRC also could not garner adequate support for a disease that was the biggest killer. A larger support for the approach has to be simultaneously garnered for the programme to succeed. Foregrounding the social determinants of health as well as the limits of technological interventions and developing similar approaches to other health problems have to be simultaneous activities to sustain it. • Positive Lessons: • A People-centred approach is most cost-effective and makes rational use of technology. • A strong evidence- based rational programme acts as a restraint against excessive distortion.

22. Lessons contd. The Multi-Purpose Worker Scheme Meant to integrate the paramedical workers of various vertical communicable disease control programmes. MPW (male) lost the planners/adminstrators’ support due to increased emphasis on the female MPW/ANM due to the RCH programme and the ‘advice’ of funding agencies to stop support to this cadre. Then programmes had to re-invent primary level paramedics, such as Roll back malaria programme’s verticalised primary level ‘link workers’, DOTS providers etc.

23. Lessons to be Drawn from : • The Integrated Vector Borne Disease Control Programme • Integrated Disease Surveillance Programme • Integration of the Leprosy Programme • Integration of the Malaria Programme

24. Disease control: Positive Impact of NRHM on malaria and kala-azar control • The control of malaria and Kala-azar received priority in areas where these diseases are prevalent. • Strengthened by the introduction of ASHA, • Strengthening by filling up of MPW vacancies • Strengthened by filling up medical officer vacancies • Strengthened by improvement of laboratories . • Work on the elimination of kala-azar accelerated. • provision of free transport, free testing, free supply of drugs, and free diet to patient attendants and payment of Rs. 50 per day for the loss of wages. • All the PHCs visited have admitted Kala-azar patients, tested the patients and confirmed cases are treated as per the protocols. • Adequate arrangement has been made for treatment, assured drug supply and financial support for patients and one attendant.

25. Janini Suraksha Yojana • One of the public faces of NRHM • “Conditional cash transfer” approach acts as an incentive to bring a flood of new users into public health systems. • Forces attention on issues of access to care, quality of care, on issues of human resource availability and on issues of infrastructure.

26. A. Increase public private partnerships. Strengthen emergency transport system.. Search for more opportunities for conditional cash transfers to achieve other programme goals. Provide more inputs to public facilities to improve quality of care and increase 24*7 delivery services, emergency obstetric care etc. Task shifting for achieving skills needed (human resources for maternal health), B. Using this as an opportunity for achieving “fully functional health facilities faster.” Solve human resources for public health by increasing nursing education and multi-skilling in major way; Supplementing gaps with private partnerships. Strengthen traditional birth attendant capacities with backup referral and emergency transport Strengthen emergency transport system.. Strengthen newborn and child care in PHCs and CHCs- providing minimum norms and support for the same. Potential Impact of JSY on health systems….

27. Current: Begins with IMNCI. Immunisation: Vitamin A – in two drives. Zinc for diarrhoea. SNCU in some hospitals. Skilled birth assistance in some areas and “emonc” in some facilities. BCC, malnutrition and anemia missing.. School health.. Here and there, this and that.. Systems approach: Begin with protocols for ASHA(Home based care for sick child), for AWW(IMNCI), for subcenter(IMNCI), fro PHC(SNCU-1) for CHC(SNCU-2) and for DH(SNCU-3) and for school health Build in Nutrition Rehab. Centres Skill and support health care providers to deliver these services Build up logistics to support it. Build up BCC and community mobilisation to support it including VHND strategy> Monitor and support these services. Build up a district resource team and management team to lead all of this: (vitamin A and immunisation part of sub-center protocol, zinc part of IMNCI) Example: Child Health:

28. What drives vertical programmes… • The central state- divide where the central funding determines key programmes while state funding is limited to salaries/establishment. • The influence of donor agreements and their priorities. • The structures and privileges that have developed over time vested in vertical structures. • An ideological perspective that public intervention should be limited to few cost effective programmes for few pragmatic internationally prioritized objectives- not try to provide “everything for everyone” and to leave other private care to market forces. • An understanding/influence that prioritizes those investments in public health that help develop markets- for products, for services.., with a bias towards markets for corporate structures..

29. How do we articulate needs for integration: without challenging the ideological perspective • Monitoring: how monitoring of each programme depends on the other and is more efficient and effective: How it can, in turn, be used to promote better management and achieve convergence. • Human Resource Development: all programmes need doctors , nurses, health workers, managers: tendency to grab those available for vertical priorities. But yet without a common plan for development of health resources it is almost impossible to develop these resources- and without synergy one cannot rationalize use. • Human Resource Development: Skill development: not possible to access in-service human resources for skill development without synergy. • Planning- especially district level and village level: why it is needed for more effective vertical programmes , and in turn how its leads to better allocation of resources. • Infrastructure planning: Funds available for infrastructure from each programme can be leveraged for all without sacrificing commitments to funding agency.

30. ISSUES • How do we look at non-communicable disease programme.. Can we have national cancer control programme, national diabetes control programme, national goiter control programme, national cardiovascular disease control programme, national fluorosis control programme, national mental health programme, national dental health programme, national epilepsy control, national anti snake bite programme etc etc? • Should we limit all the above programmes to only providing research and resource inputs and insist on integration of all these? • Current national programmes account for only 19% of morbidities- what about the rest.. • Needs to be built into the concept of Fully Functional Health Facilities- & Indian Public Health Standards

31. What could be an alternative perspective on integration and convergence? A. Health systems development is the main approach with health programmes being interim measures. B.District Health Systems development is needed because it can lead towards: • Decentralised governance • Public participation in health governance. • A citizen-responsive health system. • A more effective and equitable health system. • A more rational and cost-effective health care system.

32. C. Programmes for special focus Communicable Ds. and NCD to be designed for horizontal integr. based on: • Epidemiological priorities, • people’s felt needs, and • health service system context.

33. THE CHALLENGES • Developing Human Resources to provide integrated services gauranteed at each facility. • An HMIS supportive of integrated monitoring. • Integrated administrative and financial structures to supervene over the present fragmented structure to allow more need-based and cost-efective planning. • Evolve planning processes conducive to integrated health care.

34. Thank You