Key Findings Recommendations . of the 4th CRM, 2010

1. Key Findings & Recommendations�. of the 4th CRM, 2010 Presentation on 26th February 2011

2. 11 Themes, 15 states INFRASTRUCTURE HUMAN RESOURCES FACILITY DEVELOPMENT OUTREACH SESSIONS ASHA REPRODUCTIVE AND CHILD HEALTH NUTRITION DISEASE CONTROL PROGRAMME MANAGEMENT FINANCIAL MANAGEMENT DECENTRALISATION

3. 1. PROGRESS IN INFRASTRUCTURE

4. Recommendations To close gaps in high focus states- need to have clear prioritization plus state and district level �autonomous� institutional arrangements as a pre-condition Add beds where beds are needed- facility mapping as basis needs to be emphasised Most states need orientation on hospital infrastructure planning. Need to put in place technical guidelines More progress on residential accommodation needed- but prioritize where to take up (currently there is progress but also problems of utilization)

5. 2.HUMAN RESOURCES FOR HEALTH Earlier improvements sustained: Estimated 100,000 contractual employees working under NRHM Vacancies remain high in specialists & even multi-skilling roll out too slow. Improvement in medical officers recruitment� In ANMs and Nurses � plateau in recruitment. Situation set to change dramatically with rapid increase in availability around the corner : Increase from 275 institutions to 1032 in the high focus states in 5 yrs, 42 in North East. Bihar alone needs to begin. 300% increase nationally. Needs change of service rules & Creation of posts

6. 2.Retention strategies

7. NB. Kerala, TN, Punjab, Chandigarh- have less problems because of dispersed urbanization, and greater pool of available professionals- but even they use attraction/ retention packages. No Innovations reported from Jharkhand, Nagaland, Rajasthan, Uttarakhand, Uttar Pradesh. AYUSH MO approach being widely used, but without any mandatory programme of training in place. No fresh initiative last year!! Did central initiative slow down state efforts- without itself fructifying. Increasingly � how do we get doctors to stay in rural areas?� is not a rhetorical question!! It is an indicator of good governance and administrative competence.

8. Other HR issues Improved Workforce Management Strategies-rationalization of workforce deployment, incentives, performance appraisal. Training programmes are generally not on schedule- we need to explore the reasons- also poor prioritization of who is trained. need for full time training personnel with infrastructure strategy of involving FOGSI, NNF, Medical Colleges-strengthen � but with more nuanced understanding . training of AYUSH medical officers is urgently needed.

9. Recommendations on HR Contractual terms for regular service providers posts should be converted into regular posts � in line with IPHS recommendations. Center- state distribution of regular posts- would need to be discussed- as part of development of state HR policy. For non service providers- a long term HR policy should be put in place- that also looks at retention and up-gradation of skills. Need to Retain confidence and continuity & prevent break in the NRHM/strengthening process. Should there be such high differential between contractual and regular staff- with contractual staff being paid much less Need to Persist with contractual ANMs and nurses : These would become available in most high focus states in the coming year. Do not depend only on private sector education- need a thrust on publicly financed nursing and medical education institutions to balance the skewed expansion taking place. For high focus states :Centrally coordinated Plan for faculty development in training centers and ANMTCs.

10. 3.Facility Development Increasing Case Loads- OPD, IPD and institutional deliveries. Range of cases being seen also increasing: e.g., dengue Exceptions- Uttarakhand !! also Nagaland? Increases at all levels including primary, but proportional shift to primary sector not seen in many states. Laboratory services improved � though full range of diagnostics as specified not in place. Quality assurance measures also generally absent. Drugs supply improved- but increased patient loads increasingly co-relate with greater free access to drugs and diagnostics- especially at peripheral facilities. Outside prescriptions for drugs still a major problem and user fees on diagnostics are restrictive. Jan Aushadi Kendras of Rajasthan was a welcome and effective move to reduce out of pocket costs.

11. Patient Amenities and Quality of Care Equipment availability good, but AMCs still a problem in high focus states leading to high down times for equipment. Especially in UP. Cleanliness, laundry, electricity, water, toilets, privacy for female patients all generally improved. Uttarakhand an exception to this trend: availability of essentials like generators and baby warmers was a problem!! Electricity and water , laundry was a problem Security outsourced in DHs � but not available in CHCs/PHCs. Diet available in DH level in many states- almost never below this level. Much more needs to be done on Infection Management and Environment Plans. Quality certification of public health facilities � increasing trend across states.

12. Un-tied funds and user fees Use of untied funds also had improved. But fixed rate across facilities irrespective of case loads. User Fees persist but play a declining role. Increased only in Uttarakhand. This state is also the only state that remits 50% of its collections to the treasury. Removed for pregnant women in Punjab- already not there in all other states. Newborn still not exempt in most states. Main source of user fees is diagnostics and this limits access to essential diagnostics . High out of pocket expenditure in drugs and diagnostics still makes public health care unaffordable for many. Moves to reduce/eliminate user fees needed � but along with flexible financing to take care of local needs- as many hospitals are dependent on them for quality of care. Punjab Health Service Corporations rules for use of user fees could be adapted for expenditure of un-tied funds

13. 4.Outreach services.

14. Outreach services cont.. Work distribution between two ANMs needs to be rationalised. Male worker availability has increased. UP and Arunachal lag behind : 25% of posts only filled. Changing sub-center role- TN, Kerala, Punjab, Chandigarh, Nagaland. Uttarakhand and Assam- ANMs: still a significant contributor to midwifery services at home or at sub-center. MMUs have expanded to over 1500 across the country and were functional in most districts visited. Immunization services affected adversely if sub-center and outreach approach is abandoned �as is seen from TN . Punjab also outreach sessions are low. Sub-center level tracking arrangements weak.

15. 5.ASHA programme-a lot of good news Coordination between ANMs, AWWs and ASHAs reported as very good from most districts. Low attrition rates. Less than 5% drop outs. Good social recognition. Functionality on promotion of institutional delivery and immunization reported as very good, active in referral and follow up in disease control programmes. In Kerala playing a role in NCDs and palliative care. Strong element of mobilisation in Chhattisgarh and Jharkhand programes. ASHA sammelans in many other states. ASHA rest rooms and help desks in place in UP, Jharkhand, Punjab, Uttarakhand, Orissa. ASHAs entering ANM and nursing schools in Chhattisgarh and Orissa- through due process. 457 + 31 in CG, and 130 in Orissa. Payments improving- but wide range- Rs 350 in Kerala, rs 500 in uttarakhand to Rs 2000 in Assam and Jharkhand. Wide variability within groups- from Rs 350 to Rs 3500 in a single FGD in Orissa. Most payments is from JSY

16. ASHA program- Urgent Concerns Drug kit replenishment remains a problem Supervisory systems , ASHA resource centers, ASHA mentoring groups created in more states, but adequately functional in Chhattisgarh, Nagaland, Orissa, Uttarakhand. There is a need for training of facilitators, needs monitoring strategy, needs resource support in other states. Training programme on schedule in Chhattisgarh, Nagaland, Orissa, Uttarakhand, Arunachal, Maharashtra, and picking up in MP, Jharkhand. Training Programme Lags behind: Uttar Pradesh, Punjab, Rajasthan, Assam- especially for modules 6 & 7. Need to develop training sites and training teams, and mobilization, monitoring and support strategy : for a rapid roll out of skill based modules- 6 & 7 .

17. 6.Reproductive and Child Health Substantial improvements in institutional deliveries continues. Delivery loads more skewed towards secondary hospitals- especially the district hospital- from 40 to 70%. Only 20 to 30% in PHC/CHCs and less than 10% in sub-centers. Only about 10% of sub-centers and 30% of PHCs providing delivery services. �Premature� de-skilling of ANMs/sub-centers where home deliveries continue to be high- e.g. Uttarakhand, Punjab, Orissa. Management of complications still sub-optimal. Monitoring, post training support and even prioritisation of trainees has to improve. Training can often miss the most active service providers.

18. Facility Based RCH care Obstetric Care C- sections available in 27 out of 30 districts visited and over 76 fnal FRUs in these 27 districts. In High focus states: in 17 dts which had FRUS there were 23 FRUs: only one or two FRUs per district- usually DH. C-section rates high in Kerala. Below optimum in most high focus states. Blood available in 74 FRUs . Abortion Serv. parallel CEMONC . BEMONC training not visible - but this level of care available in many � though not all -level 2 facilities. Referral transport in place in 13 states- but efficiency needs to increase. No user fees in all states for pregnant women Child Care SNCUs functional in 5 of 30 districts visited. One district had 2 SNCUs. Few districts could have had some form of NICU. Newborn stabilisation units or other facility level care � neither through training or protocols nor equipment/staff established. Newborn corners visible now in most states- though use of equipment and skill transfers � even of NSSK level- have yet to reach service providers. User fees still charged- referral transport utilization for newborn illness limited. 1.3 FRUs per district in High focus districts, but 5.3 FRUs per district in non high focus district. 1.3 FRUs per district in High focus districts, but 5.3 FRUs per district in non high focus district.

19. Recommendations on RCH Where high levels of home delivery despite supply side improvements- study the issue and then act e.g. in Punjab, Uttarakhand.- different solutions in each�. Where low levels of home delivery or un-immunised children- identify the geographic areas where it persists- from HMIS- and develop area-specific strategies. In JSY : focus on greater quality of care as measured by increased and improved management of complications. Also delivery of cash on day of delivery Evolve Strategy of Scaling Up Facility based child care to minimum acceptable levels- with some provision for sick newborn and child care in all level 2 and level 3 facilities � must be worked out. Urgent need to roll out home based newborn care , community level management of common illness in children and nutrition support �.in view of persistent high under 5 child mortality. ( training, pregnancy tracking, maternal death review ,HR discussed elsewhere)

20. Pregnancy and Child Immunization tracking Finding: 4 states/ 15 have started tracking- rest are still in preparatory phase and overcoming constraints. No clear method of judging quality of data uploaded and usually too incomplete for use. Interpretation: System�s use of this effort for closing gaps or for planning interventions- not present. High increase in work load but benefits uncertain. Recommendation: Need process evaluation and substantial design improvements for making it more useful and less labour intensive. Maternal death reviews- processes rolled out. But interpretation and use of data needs further effort.

21. 7.Nutrition More states report action on infant and young child feeding- notably Uttarakhand and Jharkhand and Orissa. Take Home rations for children below 3 years not available in many states. Positive reports on food supplementation for older children and mid day school meals. Good progress in Nutrition Rehabilitation centers in Madhya Pradesh, Maharashtra, Chhattisgarh, Assam, UP, Rajasthan and Jharkhand- though utilisation a problem in latter states. Bal Swasthya Poshan Mah & Swashtya Kishori Mah celebrated in UP. Bal Shakthi Yojana in MP. School Health Programme reported from most states- not assessed in detail . Positive reports from Kerala, Chandigarh.

22. 8.Disease Control Programmes Integration with NRHM at district and state levels better. Sustained performance in RNTCP/Low case detection rates reported from Arunachal, Punjab, Jharkhand and UP. Improvements in Orissa, MP, Rajasthan and Maharashtra. In Malaria- Assam, Orissa, MP show improved availability of supplies- while problems persist in Chhattisgarh, Maharashtra, Kerala. � , lack of supplies expired drugs, OOP purchase of life saving anti-malarial etc. NLEP ( leprosy)and NPCB( blindness) � positive reports- some concern of increased prevalence from Orissa. IDSP- flow of information established- but public health response to reported outbreaks and disease report patterns very weak. Also not used for planning.

23. 9. Programme Management State and District Health Societies � perform better, coordinated better. Fragmentation and set back in management in Uttar Pradesh. SHSRCs are in place in Chhattisgarh, Punjab, Maharashtra, Kerala, Jharkhand: also in Uttarakhand and Rajasthan. NE �RRC supports the three NE states- Assam, Arunachal and Nagaland, But TN,UP, MP, Orissa: not yet started. RKS functional and improving in most states. Most still managing mainly untied funds and user fees. Procurement and logistics institutions not proceeded beyond the first two- TN and Kerala. Punjab�s HSC- in place- but not as effective in logistics.

24. Health Management Information Systems.. Flow of information established in all states. Use of information is now reported from a number of states- especially Orissa, Chhattisgarh, Punjab, Chandigarh, Tamilnadu, Kerala, Assam- but others have yet to start. Even in these states feedback is weak. In other states it is non existent. Problems in data quality due to poor design of recording registers, duplication of data at periphery and need for intra-hospital systems in large hospitals. Data from private sector- still at initial stages except in a few states eg Kerala. But where efforts are made the response is good. Many states have local systems running and other applications developing � hospital management, Human resource management, GIS etc. What is needed is to impose standards of interoperability and build data standards, data policy. Currently state systems unable to connect and efforts to engulf all in a single national system neither feasible nor desirable.

25. Financial Management Considerable strengthening of accounting processes- with manpower, e- banking systems, customised Tally etc. However still problems of absorption of funds persist due to Activity wise transfer of funds from state to district. Untied funds � and programme funds blocked in facilities/blocks with poor turnover. Lack of guidelines. Slow programme implementation- due to inadequate management structures. Lack of state financial leadership- need separate accounts manager and finance manager- often conflated. Need senior officer as director finance � only few states have this in place.

26. Decentralization District Planning effort has weakened in many states. Still good in Kerala, Orissa, Jharkhand, Arunachal, Nagaland, Punjab. In many places it becomes a template filling exercise- and funds do not flow as per plan. Post sanction re-alignment often not done. Use of HMIS and IDSP in plan formulation limited. Facility level data analysis needed- but web-portal entry does not lend itself to analysis and that has to be done off line or by parallel system. VHSCs formed- but functionality limited- however fund utilisation improving and there is considerable outputs � like AWC up-gradation, vector control and sanitation work, local mobilisation events. Village health planning as such is not picked up. Role even in VHNDs are limited. More clarity on their mandate needed.

27. Public Participation in Health Systems� PRI involvement still limited to representation in RKS and district health societies and the VHSC RKS not yet a vehicle of public participation. More a vehicle for user fees and now untied funds. Allows local decision making. Community monitoring- positive reports from Maharashtra, Madhya Pradesh, Rajasthan, Orissa, and Chhattisgarh. However being taken forward only in Maharashtra. NGO participation declining. Even in areas like community monitoring, outreach service delivery, ASHA or VHSC training etc. A 5% of NRHM funds through NGOs would be a distant goal.

28. Innovations Boat Clinics in Assam and Kerala. Non communicable disease initiatives in Chandigarh, and Kerala. Medical care for victims of gender related violence/social abuse in Kerala. Child development services for children with special needs- in Kozhikode. Birth waiting home from tribal Maharashtra. And Many Others�.

29. Across the 4 CRMs- What has been improving. Increasing Case loads in public health facilities. Increasing institutional deliveries. ASHA functionality and effectiveness. Increase in Human resources- esp. Contractual staff at management levels ANMs and nurses Medical officers Strategies for retention of skilled workers . Mobile medical units Referral transport systems. Health Management Information Systems and use of Information.

30. Across the 4 CRMs- What else has improved�. Massive expansion of nursing education- over 3000 institutions- 1070 of these in the high focus states Increasing state expenditure on health: A 14% annual increase in state health expenditure in 2005-06 to 2008-09 as compared to a 4.1% annual increase between 2001-02 and 2004-05. In High focus states it was 14.4% , in NE it was 22.4% and in Others it was 12.9%. Functioning of state and district health societies and RKS. Mainstreaming AYUSH- both co-location and increased access to AYUSH services- and use of AYUSH practitioners as medical officers

31. Across the 4 CRMs- What has improved too slowly or plateaued? Increase in specialists or those trained and used in specialist skills.(multi-skill trainings included) PPPs for emergency obstetric care or sterilisation services Training in SBA and IMNCI, Quality of district planning User fee reduction and free drugs in facilities. Support systems for ASHA & other CP Community Monitoring. SHSRCs Management institutional structures and professionalisation of management Ability to absorb funds.

32. Across the 4 CRMs- What never took off or declined? TNMSC type procurement and logistics system- NGO participation started well � but declined Training for BEMONC & F-IMNCI � Public health cadre Effective convergence action- measurably on social determinants.

33. Health Outcomes- --How near? How Far?

34. TFR 2008 34

35. TFR- 2006 Small States

36. MMR 2005-06 � Large States 36

37. Big four is 72%; 9 states of 3% each 33.9Big four is 72%; 9 states of 3% each 33.9

38. IMR 2009 � Large states 38

39. IMR 2009 � Small states & UTs 39

40. Big four is 55%Big four is 55%

42. The Last Year of the XI th Plan- and the build up for the XII th Plan. For TFR and MMR: There is a case for a special effort in the six large high focus states where majority of districts are poor performing and all districts that are poor performing in the other large states. For under 5 mortality- there is a need to leverage the ASHA programme in all high U5MR states, even as we strategize the scaling up of the facility based child care. For infectious disease beyond the national disease control programmes and chronic disease control there is a need to leverage IDSP and district planning efforts � to scale in the non high focus states�