Meeting People's Health Needs: Workshop on Financial & MIS Monitoring
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Presentation Transcript
Meeting People’s Health Needs Overview Workshop on Financial & MIS monitoring Mussoorie, May 2007 Ministry of Health & Family Welfare, Government of India
It has been over seven years since we turned one One billion
overview • Total Population : ~ 113 crore • Rural Population : ~ 75 crore • States : 35 Districts : 609 Blocks : 6345 Villages : 638,588 • Total doctors in country : 767,500 • Number of doctors at PHCs : 22,273 • Number of specialists in public system : 3979 • Number of ANMs : 149,695 • Medical Colleges : 262 • Nursing Colleges (GNM) : 979
+ 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
Strengths of the Health System • Extensive framework and reach even in many difficult areas. • Established procedures in State Health Directorates • Presence of active Non Governmental service providers • Recent Achievements • Leprosy eliminated at National level • Neonatal Tetanus eliminated from 9 States. • TB cure rate sustained at more than global target of 85% • Efficient response to Avian flu • Medical Tourism Why NRHM ?
+ HEALTH INDICATORS * : SRS
- THE CITIZEN’S PERSPECTIVE Lack of Holistic Approach Health not a priority. Under funded, yet not utilised. Shortage of infrastructure & human resources Lacks community ownership and accountability Non integration of Disease Controlprogrammes Non responsivenessto Citizen
Burden of Disease • Demographic transition • Communicable diseases still major burden. • Additional burden of non-communicable diseases. • Sedentary lifestyle and unhealthy diets. • Future reforms and initiatives to strengthen the health care system must give priority to the primary sector.
- Public Health - Concerns • Sustainable Systems • Financing Spending 5.2 % of GDP ( Private 4.3 %, Public 0.9%) • Infrastructure (over 2,00,000 facilities) • Manpower • Logistics • Management • Evaluation • Responsive & Equitableto citizens
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
EXPECTED OUTCOMES 2005 - 2012 • Universal Health care, well functioning health delivery system. • IMRreduced to 30/1000 live births by 2012 • MMRreduced to100/100,000 live births by 2012 • TFR reduced to 2.1 by 2012 • Malaria Mortality Reduction Rate – 60% upto 2012 • Kala Azar eliminated by 2010, Filaria reduced by 80 % by 2010 • Dengue Mortality reduced by 50% by 2012 • TB DOTS series – maintain 85% cure rate • Responsive Health System
The Formative Years
The formative years • 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 • MoU signed by all the states • Specific Activities funded on Normative basis • Untied funds to Sub centres • Selection & Training of ASHAs • Preliminary renovations at CHCs • Preparation of District Plans
The formative years • Framework for Implementation approved July 2006 • Highest institutions of NRHM empowered • Mission Steering Group • Empowered Programme Committee • Financial envelopes to states (no schematic prescriptions ) • National Programme Coordination Committee • State Programme Implementation Plans appraised. • Monitoring systems put in place. • SPMUs/ DPMUs positioned.
The Strategies
Strategies • Improve Infrastructure • Augment manpower • Improve management • Flexibility to states to deploy funds • Decentralisation • Communitization Old wine in new bottle ?
The Tools • Substantially larger funding • Financial envelop to state (districts?) • PIP based releases (IDHAP) • Untied funds (Untied?) • Annual maintenance Grants (Sanctions?) • Decentralised procurement (capacity) • Contractual recruitment (facility specific) • Outsource as per need (RKS) • Integrate training, IEC, Training, procurement (turfs) • Financial management Group. • PIP appraisal – generic norms – EPC/MSG
The Institutional Framework • Mission Steering Group • Empowered Programme Committee • State Health Missions • District Health Missions • Rogi Kalyan Samitis • Village Health & Sanitation Committees • ASHA Mentoring Group • Advisory Group on Community Action • National / State Health System resource Centre
The Tools • Infrastructure upgradation • Sub Centres made functional • Additional contractual ANMs • Untied funds for local action • Community link worker • Village Health Nutrition committees • Expanded Medicines supply • PHCs made 24 x7 • Three staff nurses • Annual maintenance grant • Untied funds • AYUSH Integration • Rogi Kalyan Samiti • IPHS
The Tools • Infrastructure upgradation • CHCs upgradation • First Referral Units • Facility survey • Not more than 33% of NRHM outlay in high focus & 25% in non-high focus States for infrastructure. • IPHS • Untied funds/Annual mainta grant • Rogi Kalyan Samiti • District Hospital upgradation • Facility survey • IPHS • Rogi Kalyan Samiti • During XI Plan 2 : 2 : 6 ratio State : Internal : GOI
The Tools • Manpower augmentation • Multi skilling all MOs • Developing MOs as Health Manager • Filling up vacant posts/Creating more posts • Contractual positions to fill gaps • Trainings / expanding training capacity • Rational transfer and posting policy • Health sector planning • Household surveys & Village Health Plans. • Integrated District Health Action Plans. • Annual PIPs / Perspective Plans - Flexibility. • SPMUs/ DPMUs/ Block PMUs • NHSRC/ SHSRC
The Tools • Improved service delivery • Citizen’s charter • Monthly Health & Nutrition Day • Outsourcing critical service gaps • Catch up rounds of Immunisation • Improved IP & OP utilisation • Mobility Support / Mobile Medical Units • Maternity Benefit Schemes • Systemic improvements • Improved logistics. • Rational / Optimal positioning of manpower • Rational delegation (financial & Administrative) • Decentralised procurement • Partnerships with Non Government Stakeholders • Alternate Health Financing • Improved disease surveillance
The Tools Accredited Social Health Activist • Link between community and delivery system. • Chosen by and accountable to Panchayat. • Performance linked incentives. • Anchored in the Anganwadi system. • Provided with a basic drug kit. • Depot holder for contraceptives and IEC materials. • Supported by VHSC, AWW / ANM / SHG. • Linkages with functional facilities. Monitoring & Evaluation • Review meetings, State visits – evaluation teams, RDs • Integrated MIS • External Surveys • Immunisation - UNICEF • ASHA & JSY – UNICEF, UNFPA, GTZ • Financial protocols- Institute of Public Auditors • Comprehensive External Evaluations • Community monitoring
Health Planning
Planning under NRHM • Indication of resource envelope to Districts and Blocks • Perspective Plan 2005-2012. Annual Work Plan. • Broad norms and indicative resource envelope. • 70% of resources utilized at Block/sub Block • 20% at the district level. IDHAP • Convergent action with wider determinants of health • Household surveys for local use. • Facility Survey – essential requirement
Money Matters
Direction & Administration Integrated District Health Society RCH NVBDCP NPCB RNTCP IDD NLEP IDSP New In. Integrated District Health Action Plan State Programme Implementation Plan
Streamlining Fund Flow • Funds transfer to States taking 1 – 3 Months. • Electronic Transfer of Funds to States started • New system introduced wef 1st January 2006. • Cuts down security risk in funds transfer. • Business process, both within the Ministry and in the banking system, was reengineered.
Deliverables 07-08
CHALLENGES & ISSUES • Complexity of the sector (Cross linkages with poverty, illiteracy, social customs) • Governance issues • Involvement of states • Assured availability of incremental Outlays for Mission period. • Shortage of manpower / lack of capacity • Empowerment of PRIs & community
NRHM is not a scheme/project/programme • It is a overarching umbrella which seeks to strengthen the health system and improve efficiency of constituent initiatives • NRHM is not ‘new improved RCH II’ • Cross cutting / common strategies • Expanded paradigm for Health sector reform • NRHM is not about substitution of state funding by GoI funding • Performance & milestone based funding • 15 % funding by state in XI plan • Increase state budget by 10 % annually • Rationalise administrative and financial sanction powers • NRHM is not about contractual workers • Decentralised articulation of need and local site solutions instead of centrally driven recruitment/procurement/planning. • Residency criteria- recruitment against a facility-remunerate as per requirement-fill up state vacancies if they exist
The Explanatory notes
18 High Focus states which include : • 8 Empowered Action Group States : • Bihar, Jharkhand, Madhya Pradesh, • Chhattisgarh, Uttar Pradesh, • Uttaranchal, Orissa and Rajasthan • 8 NE States • Himachal Pradesh and Jammu & Kashmir. • High Focus states are entitled to : • Fund allocation with weightage of 1.3 (for NE states 3.2) • support for all ASHAs • 30 % of allocation may be deployed for civil construction • Other than High Focus states are entitled to : • Fund allocation with weightage of 1.3 (for NE states 3.2) • Support for ASHAs in tribal and underserved areas • Support for Link workers under RCH II • 25% allocation may be deployed for civil construction • All other strategies are applicable in the same manner uniformly across all states
Annexures • Composition of • Mission Steering Group • Empowered Programme Committee • State Health Mission • District Health Mission • Rogi Kalyan Samitis • Advisory Group on Community Action • Asha Mentoring Group • Explanatory Notes • Illustrative State Innovations
