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NRHM

Meeting People’s Health Needs. NRHM. 16 th June 2008 National Institute of Public Cooperation & Child Development ToT of AWTCs/MLTCs National Rural Health Mission Ministry of Health & Family Welfare Government of India. India a snapshot. Total Population : 1.1 billion

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NRHM

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  1. Meeting People’s Health Needs NRHM 16th June 2008 National Institute of Public Cooperation & Child Development ToT of AWTCs/MLTCs National Rural Health Mission Ministry of Health & Family Welfare Government of India

  2. India a snapshot Total Population : 1.1 billion Rural Population : 742.7 million Number of Administrative units States : 35 Districts : 609 Blocks : 6345 Villages : 638,588 HR as per World Health Report 2006. World Health Organization, Geneva.

  3. National goals & MDG context

  4. India’s Health Indicators Large inter state variations

  5. Large inter state variations • Reference: IMR - SRS 2006 • MMR -SRS 2001-2003

  6. India’s child survival challenge • Birth rate 24.1 (2004) • 27 million neonates to take care • U5MR 95 (1998-99) • 2.5 million die before completing 5 years • Globally India accounts for 23% of all U% deaths • IMR 57 (2007) • 1.6 million die before completing 1 year • 64% of infant deaths occur in the first 30 days. • More than 50% occur in first 3 days • NMR 40 (2002) • 1.1 million die before 4 weeks of age

  7. Health delivery apparatus • Public Sector facilities • Private Practitioners • ESI, CGHS, PSU Hospitals • Railways Hospitals • Armed Forces Medical Services • Corporate Hospitals • Indian System of medicine • Informal providers • Quacks/Crooks & magico religious practitioners

  8. Sub-Centres (SCs) • Most peripheral contact point with primary health system • One ANM and one Male Health Worker • One Lady Health Worker (LHV) supervises six Sub-Centres. • Tasks relating to interpersonal communication wrt maternal and child health, family welfare, nutrition, immunization, diarrhea control and control of communicable diseases programmes. • Provided with basic drugs • 100% Central assistance to all the Sub-Centres since April 2002 • There are 1,45,272 Sub Centre as on March, 2007

  9. Primary Health Centres (PHCs) • First contact point with Medical Officer. • Envisaged to provide an integrated curative and preventive care • Established and maintained by the State Governments underthe Minimum Needs Programme (MNP) • Manned by a Medical Officer supported by 14 paramedical and other staff. • It acts as a referral unit for 6 Sub Centres. • It has 4 - 6 beds for patients. • There are 22,370 PHCs as on March, 2007 in the country

  10. Community Health Centres • Established and maintained by the State Government under MNP/BMS programme . • It is manned by four medical specialists i.e. Surgeon, Physician, Gynecologist and Pediatrician supported by 21 paramedical and other staff. • It has 30 in-door beds with one OT, X-ray, Labour Room and Laboratory facilities. • It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultations. • As on March, 2007, there are 4045 CHCs functioning.

  11. The Structure of the Public Health System • Health is a State Subject Family Welfare is Concurrent. • Primary Health care is Local self Government. • Most institutions and manpower are in state sector. • Most programmes are in the central sector • National Programmes address about 25% of all morbidities. • No dedicated health functionary at village level. • 1st Doctor at PHC (30,000 population),1st Specialist at CHC (80,000 popu).

  12. Deep rooted structural issues • Sustainable Systems • Financing 5.2 % of GDP ( Private 4.3 %, Public 0.9%) • Infrastructure (over 2,00,000 facilities yet inadequate) • ManpowerWorkforce Issues: Irrational distribution; Poor work culture; absenteeism; Poor supervision • Logistics • Management • Evaluation • Responsive & Equitableto citizens

  13. 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

  14. Goals of the Mission • Universal Health care, well functioning health system. • Reduce IMR to 30/1000 live births by 2012 • Reduce MMR to 100/100,000 live births by 2012 • TFR reduced to 2.1 by 2012 • Reduce & sustain Malaria Mortality to 60% by 2012 • Kala Azar eliminated by 2010, Filaria reduced by 80 % by 2010 • Dengue Mortality reduced by 50% by 2012 • TB DOTS maintain over 70 % case detection & 85% cure rate • 46 lakh cataract operations annually by 2012. • Upgrading all health facilities to IPHS. • Increase utilization of FRUs from 20% bed occupancy to 75%

  15. The formative years of NRHM • Original approval for NRHM in January 2005 • Country wide Launch by Prime Minister, 12 April 2005 • 2005-06 was formative year during which • Strategies & Guidelines firmed up • Merger of Deptt of Health & family welfare • State & District Health Missions constituted • Specific Activities funded on Normative basis • Framework for Implementation approved July 2006 • Highest institutions of NRHM empowered • Mission Steering Group • Empowered Programme Committee • Financial envelopes to states, NPCC • Monitoring systems & Management structures put in place.

  16. The Paradigm Shift

  17. The Paradigm Shift • Decentralised planning • Outputs and Outcome based • Pro-Poor Focus: Equitable systems • Quality of Care and the IPHS norms • Rights based service delivery • Pre stated entitlements at all levels • Inputs computed as function of the entitlements and estimated patient load • Judicious mix of dedicated budget lines - untied funds • Monitor quality • Community Participation

  18. The Paradigm Shift • Bringing the public back into public health • At hamlet level : ASHA, VHSC, SHGs, Panchayats. • At the facility level: RKS • At the management level : health societies • Governance reform • Manpower, Logistics & Procurement processes. • Decision making processes • Institutional design, Accountability framework • Convergence • Water and sanitation • Nutrition • Education

  19. Monitoring & Mentoring • Regular review meetings • State visits – evaluation teams, SFTs, RDs • Integrated MIS (web based) • External Surveys • Immunisation - UNICEF • ASHA & JSY – UNICEF, UNFPA, GTZ • Financial protocols- Institute of Public Auditors • Concurrent External Evaluations • Concurrent Financial Audit at District level by external CAs • Financial Audit of SHS/DHS by CAG CAs • Community monitoring – AGCA/PFI • ASHA Mentoring Group • JRM & Common Review Mission

  20. Community empowerment under NRHM • Not (only) Community Monitoring but Empowerment • Part of over all health sector reform agenda • Embed Community ownership within reform processes • In programme design of all strategies (PPP, Insurance etc) process monitoring by the community needs to be built in. • More than grievance redress forum or adverse impact analysis • Covers planning, designing, implementation as well as ongoing concurrent oversight. • Does not have large budgetary footprint Not all reforms have budgetary implications.

  21. Contours of Community empowerment

  22. OBJECTIVES • Create forums for community ownership VHSC, RKS,DHM,SHM • Collect systematic info about community needs • provide feedback according to • locally developed yardsticks • key indicators. • Do with salary based systems what seems possible only with passion based systems. • Validate sector wide data from other sources • Triangulation

  23. Tools of Community Monitoring Village Level • Village Health Register - Records of ANM - Public dialogue • Village Health Calendar- Infant and maternal death audit PHC level • Charter of Citizens Rights – IPHS - PHC Health Plan Block level • IPHS - Charter of Citizens Rights - Block Health Plan District level • Report from the PHC Health committees • Report of the District Mission committee • Public Dialogue (Jan Samvad) State level • Reports of the District Health committees • Periodic assessment reports by taskforces / State level committees about the progress made in formulating policies according to IPHS, NHSRC recommendations etc.

  24. Issues to be monitored MCH,JSY,ASHA,VHSC Untied funding Disease Surveillance Curative care etc Scores Good Performance Cause for Concern Poor Performance Village Health Score Card Methods Village Group Meeting Interviews with beneficiaries Interviews with ASHAs etc

  25. Issues to be monitored Service availability, Quality Equipment, Supplies, Personnel Charges, Corruption RKS Functioning etc Scores Good Performance Cause for Concern Poor Performance Facility Score Card Methods Facility Observations Meetings with Providers Exit Interviews etc

  26. Community Monitoring Committees

  27. Village Health & Sanitation Committee • Gram Panchayat members from the village • ASHA, Anganwadi Sevika, ANM • SHG leader, the PTA/MTA Secretary, village representative of any Community based organisation working in the village, user group representative Chairperson would be the Panchayat member Convenor would be ASHA / Anganwadi Sevika of the village. Formed at level of revenue village (more than one such village may come under single Gram Panchayat).

  28. PHC Level Committee • 30% members : representatives of Panchayati Raj Institutions (Panchayat Samiti member from the area; two or more sarpanchs) • 20% members - non-official representatives from VHSCs with annual rotation to enable representation from all the villages • 20% members representatives from NGOs / CBOs in the area • 30% members representatives of providers, MO, ANM Chairperson be one of the Panchayat representatives, Executive chairperson be Medical officer of PHC. Secretary be one of the NGO / CBO representatives.

  29. Block level Committee • 30% members representatives of the Block Panchayat Samiti (Adhyaksha / Adhyakshika of the Block Panchayat Samiti or members of the Block Panchayat samiti, with at least one woman) • 20% members be non-official representatives from the PHC committees with annual rotation to enable representation from all PHCs over time • 20% members be representatives from NGOs / CBOs • 20% members be officials : BMO, BDO, selected MOs from PHCs etc • 10% members should be representatives of the CHC level RKS Chairperson be one of Block Panchayat Samiti reps. Executive chairperson be the BMO. Secretary would be one of the NGO/CBO reps.

  30. District Level Committee • 30% members be representatives of the Zilla Parishad (esp. convenor and members of its Health committee) • 25% members be district health officials, including DHO/ CMO/ Civil Surgeon and representatives from DPMUs • 15% members be non-official representatives of block committees, with annual rotation • 20% members be representatives from NGOs / CBOs • 10% members be representatives of RKSs in the district Chairperson be one of ZP reps preferably convenor of the Zilla Parishad Health committee. Executive chairperson be CMO / CMHO / DHO Secretary be one of the NGO / CBO representatives.

  31. State Level Committee • 30% members be elected reps in legislative body (MLAs /MLCs) or Convenors of Health committees of ZPs by rotation • 15% be non-official members of District committees, by rotation • 20% members be representatives from State Health NGO coalitions • 25% members would belong to State Health Department incl Secretary HFW, Commissioner Health, officials from Dt. of Health Services, NRHM Mission Director) along with experts from SHRC / SPMU • 10% members be officials belonging to other related departments Chairperson be one of the elected members (MLAs). Executive chairperson would be the Secretary HFW. Secretary be one of the NGO representatives.

  32. Role of Monitoring Committees

  33. Role Of VHSC • Create Public Awareness about programmes. • Discuss and develop Village Health Plan. • Maintenance of a village health register. • Ensure that ANM and MPW visit village on fixed days. • Get bi-monthly health delivery report from service providers. • Discuss every maternal & neonatal death in village. • Convener (ASHA or AWW) will sign attendance registers of the AWWs, Mid-Day meal Sanchalak, MPWs, and ANMs. • MPWs and ANMs to submit a bi-monthly village report to the committee along with the plan for next two months. • Format and contents of the bi-monthly reports would be decided village health committee. • The committee will receive funds of Rs.10,000 per year. This fund may be used as per the discretion of the VHC.

  34. Role of PHC Committee • Consolidation of village health plans • Charting out the annual health action plan & a PHC Health Plan • Disseminate Charter of citizen’s health rights • Monitoring of physical resources at PHC • Coordinate with local CBOs and NGOs • Review functioning of Sub-centres operating under the PHC • Initiate action on instances of denial of right to health care. • Contribute to ACRs of MO/ other functionaries at the PHC. • Take collective decision about untied funds utilisation.

  35. Role of Block level Committe • Consolidation of the PHC level plans and preparing block plan. • Review of progress difficulties at PHCs and CHC. • Analysis of neonatal & maternal deaths & other indicators. • Monitoring of the physical resources at the CHC • Coordinate with local CBOs and NGOs • Review functioning of Sub-centres and PHCs • Initiate action on instances of denial of right to health care.

  36. Role of District level Committee • Monitor Health committees at lower levels, Financial reporting and solving blockages in flow of resources. • Monitoring of physical resources at all District Health facilities • Progress report of Health facilities esp referral utilisation. • Charting out Integrated District Health Aaction Plan • Ensuring proper functioning of the RKS. • Discussion on Health Policy of the state level – local relevance. • Initiate action on instances of denial of right to health care.

  37. Role of State level Committee • Manage programmatic and policy issues. • Review and contribute to State Health Plan & NRHM PIP. • Issues arising from District Committees relating to state action. • Institute a Health rights redressal mechanism. • Assessing progress made in actualization of the Right to health care at the state level. • Proactive dissemination of GOI guidelines.

  38. Village Health Report Card

  39. Village Health Report Card

  40. Village Health Report Card

  41. Cumulative Report Card - Villages

  42. Facility Score Card

  43. Facility Score Card

  44. Cumulative Facility Score Card

  45. Community Monitoring Phase 1

  46. Scale of Phase 1 • Nine States • 38 districts (3-5 districts per state) • 114 blocks (three in each district ) • 342 PHCs (three in each block. • 1710 villages (five revenue villages per PHC).

  47. Features of Phase I • Green field activity • Work of Capital nature : Institutions, Committees, Orientation material, formats, channels of reporting to be developed • Advisory Group of Community Action is the operational partner • AGCA through Population Foundation of India is vehicle for • Start up activities in the initiative. • Preparation for basic documentation • Handholding the finalisation of G Orders/Resolutions • Handholding the formation, orientation and operationalisation of committes • Phase 1 funding by MoHFW is to PFI. • Funds passed to State Nodal NGOs by PFI. • District & Block level funds disbursed by State nodal NGO. • Sustenance of CM will be through state PIP

  48. Features of Phase I • MOHFW has allocated funds to PFI for : • Support for preparation of orientation material, • Travel of mentoring group members to states • State preparatory meetings, workshops, orientation material, travel and meeting expenses. • District workshops, expenses for committee formation and orientation • Village, PHC and Block levels orientation sessions, travel • Travel support to mentoring team from AGCA

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