NRHM 3 rd CRM ,Nov 2009

1. NRHM3rd CRM ,Nov 2009 Dissemination Workshop 22nd December 2009

2. CRM seeks to gauge change in Change in key aspects of Health delivery system and progress against the approved PIP of the state. Cooperation of state in the review process – acknowledged Briefing by Secy HFW and at least some participation of Director(s) Health would have added value. Findings Summary - Land of contradictions Just a short distance away from comprehensive improvement of health services with minor tweaking at critical tipping points. Institutional Framework of NRHM needs to be operationalised . SHM, DHM, RKS, VHSC, VHND, SPMU, DPMU, Block PMU, Programme Officers at state & district level, Web based HMIS, regular FMR, concurrent audit, Tally ERP9

3. Infrastructure • Substantial improvement since launch of NRHM. • Key Issues: • Sustainable plan for Construction work. • Who owns up the infrastructure & equipment. • Who is the Facility In charge accountable for maintenance of equipments, lighting, civil construction, plumbing, water supply, electrical supply. • Big structures need Big HR, and even bigger support HR. This is not factored in at many places.

4. Human Resources Planning • Multilayered issues • Insufficient numbers in some cadres • Inefficient spread • Suboptimal skill mix • Poor work culture • Poor technical and managerial supervision. • Radical reforms are needed. Many bridges crossed. • System utilises its HR for only half day. • Full complement of specialists services only the OPD • Equipment needs to match need and ownership ensured. • Ward staff is found to be universally inadequate and shortage of cleaning and maintenance staff is reported at almost all facilities.

5. Human Resources Planning • A policy on posting, transfers of HR needed immediately • DRAS CHC has only two docs and needs more. PHC shargul has only one doc. A doctor says at Kargil been there for 22 years , yearning for better posting for his children and family. 33 docs are posted in CHC Pulwama?? • HR is often unclear of its work profile, MOIC needs to remedy this. • Guidance by head of institution to the employees - entirely missing. Need to document supervision transactions • Functioning of training institutions needs substantial improvement • Multiskilled training - few persons seen, that too at places where their trainings are not most suitable • Concept of “Attachment” – Boon or bane ?

6. Preparedness of facilities & Assessment of case load being handled • Better OPD attendance at most facilities. Compared to past and to base line of NRHM - rise in various service utilisation parameters and a comparative chart presented by the state. • Due to its O&M & weak record management , the system can really not be audited for efficiency, efficacy or cost efficiency. • Substantial installed capacity created for OPD, IPD, procedures, both minor and major, dental care, lab facilities and so on. • Need to improve quality and standards –Who supervises ?. • Address quality gaps • rational medical treatments, availability of medicines and consumables, ensuring patient comfort, heating, toilets, drinking water, food etc.

7. Preparedness of facilities & Assessment of case load being handled • No specific provision for safety or comfort of service provider (male or female). This approach continues to service delivery to patients also. • Front office does not record substantive information about patients. • This compromises service tracking and hence service costing consequent fixing of accountability. • Medicines consumed, lab tests etc not attributed to specific case. • SoPs for basic services – technical components and quality issues • Prescribing habits of employees need to be improved.

8. Preparedness of facilities & Assessment of case load being handled • Monitor OPD/IPD load per consultant, procedures, lab tests. • Three lady docs posted for maternity clinic-running 10 to 4 with no deliveries is obviously a serious matter • Establish basic, non negotiable list & quality of services at ER, OPD, ANC, LR, OT, Ward etc. • Admitted patients need to be owned up by a particular doctor and treatment line /nursing care visible in the case papers. Water, food, toilets, attendants' comfort for IPD ? • Designated ER staff/nurses & equipment & general staff.

9. Preparedness of facilities & Assessment of case load being handled • Normal deliveries are conducted at most PHCs (no deliveries at SCs) • The labour rooms are reasonably clean, privacy ensured. Several quality Issues with Institutional delivery ? • Missing Links to Infection prevention, Partograph, ? 24 hour stay, RTI/STI counselling/treatment •  Blood banks – constructed – not registered ,not functional • Ensure Maternal death audit. • Untied funds, AMG and RKS funds must reach all levels.

10. Diagnostics • Large number of lab technicians available (more being recruited) . • Work audit, utilisation by clinicians and the range of services available • Logistics & Supply chain management • Annual indent system not working well in some places. • EDL not seen displayed for benefit of the patients. • Large number of pharmacists in public system (more being recruited). Do we need so many?. Alternately can we multiskill them.

11. Decentralized Planning • IDHAP ? • Posting of HR , procurement and supply of most equipments, furniture, drugs and consumables Centralised. • DHSs need mentoring to operate in a decentralised paradigm. • Rational, norm & need based recruitment, audit of service. • Tighten the accountability framework. • Decentralised Local health action • Decentralized planning not yet internalised by the state • Ownership of respective level by the CMO, BMO and facility MO. • Unless specific officer is responsible for specific facility, confidence for decentralized local health action will not take firm root. • Absence of this ownership seen as the most critical bottleneck to local health action.

12. ASHA • Selection is mostly by PHC with MLA suggestions, in absence of PRI. • Training –two rounds-is halfway (3 books??). First training was for 7 days. • Money is given by cheques. Inconvenience due to distant banks. • All ASHA got Rs 150 pm for vaccination-mobilisation treated as salary • JSY money given but most had about one case per month. • This deprived them of 2-3 days of family work. Net income was often 100- 150 per case and even that was spent for buying things children so real income is abysmal. Some spent more money on transport (500 Rs).

13. ASHA • Medicines-paracet, FS and ORS given, replenishing an issue • have not been supplied for six months now. • Some estimates that 40% ASHAs have left work already. • It is felt that ASHA programme is functioning at minimal level and ASHA’s labour is not compensated by NRHM due to the envelope constraints and paucity of delivery cases. • Mentoring group at state-district level for ASHA? • State can revamp the ASHA scheme with some extra resources from the state budget.

14. Web Based HMIS • The data quality and regularity needs to be improved • 21.8% decrease in ANC registrations from Q1 08-09 to Q1 09-10. • 30.8% decrease in deliveries conducted at public institutions • Proportion of such deliveries discharged in under 48 hours has increased from 7.5% to 44.6%. • Proportion of newborns weighed at birth has decreased by 22.4% and the number of newborns weighing less than 2.5 Kgs has increased to 21.7% in Q1 09-10 from 14.4% in Q1 08-09 • Progress against approved PIP of state • The PIP has evolved and the general direction is towards softer issues

16. FY 2009-10

17. RCH II • Quality needs to be addressed • At a DH there was no baby tray, delivery tray, record of monitoring of maternal parameters like pains, Cx or even FHS, no partograph, doppler. No poster of universal precautions, no biowaste procedures, poor aspetic precautions, and no EmOC set up either. Patient buying essentials • Concept of neonatal care as a planned intervention not clear Defaulter tracking through tickler bags etc not done & sometimes counterfoils of immunisation cards given away / or not being filled • ARSH services not available at most places. • Limited understanding of the concepts of infection control and management, and waste segregations and disposal. • VHNDs are really immunization days only. • Protection from radiation leakage posing hazard in most facilities. • No supply of IFA tablets in most facilities visited.

18. Recommendations • Paramedical council, regulatory bodies, Nursing Act and Nursing cadre.(Nursing & Midwifery Council, Pharmacy Council ) • Transfer & Postings Policy • Simplified Recruitment processes for minimising vacancies • Bifurcation of General duty doctors, Specialists and Teaching Cadres • Bifurcation of General & Specialty Nursing (Hospitals & Medical Colleges), Public Health /Community Health and Teaching cadres for Nurses and ANMs • Need an Infrastructure Development Wing at directorate level • Light up the wards, position support staff, essential equipments, • Biomedical waste & Infection management and protocols • Document and audit referrals • Prepare detailed short-term and long-term HR plan especially with regard to nursing and para-medical staff.

19. Recommendations • Provision canteen services at the facilities, telecom services, better signage (local language), temporary accommodation for attendants. Washing services for hospital linen ? Mechanised laundries /PPP • Given the terrain and the inordinately large travelling time, it may be appropriate for the state to examine a central GPS controlled ambulance service which tracks the movement of the vehicles, ensures operationalisation at all times and documents referral transport. • Asst Surgeons with PG qualifications be taken in as Specialist Gr B • Re-examine the cadre names – B Grade Specialist ? • Chemist shops run by Cooperative societies – make them generic drugs stores

20. thank you