ED NHSRC SFT presentation

1. ED NHSRC SFT presentation

2. Conceptual framework The NRHM funds state health systems. Hitherto the center was focussed only on funding a few health programmes which are on the concurrent list- disease control programmes and RCH. The central programmes account for only 19.6% of all morbidities (macro-economics commission) Success of central programmes very much dependent on health of state health systems. Large overlap between programmes and systems- and no clear demarcation possible. Improved performance of programmes needs better integration and convergence.

3. General features: General trend towards strengthening the services provided by the public health sector: reflected in increasing utilization of the facilities. Increased utilization due to increased attention Increased investment; increase in institutional deliveries due to JSY, filling up of vacancies, Untied funds being used to fill gaps in infrastructure and maintenance, Improved availability of diagnostic services and drugs. Numerous state level innovations: Varied performance of the NRHM across states. Varied performance of different programme components. States that had better baselines and that had similar programmes in place have been quick to take off.

4. Main Problems: Poor fund absorption: Rate of roll out and scale of roll out inadequate. Each state faces critical bottle-necks: Weak or absent institutional structures needed for programme as a whole and for each component. Governance issues: Human resource deficits: Problems of starting up new initiatives: poor organisation of work, lack of capacity, lack of technical assistance and resistance to change.. If in any programme component there is a less than 50% performance across states, or a problem that most states are facing, then we must be ready to examine programme design and whether we are doing enough to help… Active facilitation.. Not mere monitoring… is the need of the hour.

5. What does it take to make ASHA effective…. : A clear role definition.- state specific: A proper process of selection- are guidelines adequate? A high quality and minimum duration of training- is training schedule and in place? A Continued high quality on-the- job support- is the support structure in place The spirit of a peoples movement… Health are as an entitlement, a basic right Collective action by local communities cause change to occur. Behaviour change needs both inter-personal interaction and an enabling atmosphere Is there an understanding of ASHA as “social mobilisation”. Are the drug kits in place? Where is the hold-up Is incentive payments streamlined and adequate? personal incentive scheme to get sanction and support of the family and compensate for wage loss.

6. The critical bottle-neck across states: The support structure: A facilitator is needed ( and provided )for every cluster of ASHAs, facilitators should preferably be women who see themselves as providing local leadership to a women’s movement..they also train and support the volunteers facilitators need to be led by block and district coordinators (provided for but not in place) who need to be excellent trainers and have good people-skills and leadership skills. And this is led by a state unit which has all the above , plus a strong sense of equity and has good management capacity: ASHA resource center: Only two states have this in place. Poor partnerships with civil society and NGOs. Need to move from selecting managers to selecting community activists. Without these steps all the other problems will just not go away…

7. How does one know whether ASHA is functional? Devising indicators for each state: % of newborns who were visited thrice in first week including once in first day % of ASHAs who received more than 20 visits for common illnesses per month % of ASHAs who have referred all ( or at least half ) their pregnant women for institutional delivery. Etc etc. Deciding who will collect information and validate it while collecting it – by group processes and by village visits. Decide on frequency and heirarchy of participatory review meetings where the data flows up as well as gets acted upon States will take a long time to discover these dimensions on their own- need active facilitation:

8. The village health and sanitation committee Some states are yet to issue guidelines. Some states have issued guidelines but funds have not yet reached the committee. Some states funds have reached but situation in utilisation is not known. In some states funds have been utilised but actual outcomes are not known; and there are few plans for how to take it forwards and how to facilitate VHSCs to make and implement convergent village level health plans.

9. Untied funds: A successful component:empowering local health care providers and closing many critical gaps in service delivery. Need to assess for each state: Adequacy of guidelines – must be enabling but not restrictive. Should be administered everywhere by some participatory committee structure- the VHSC, the sub-center level committee, the RKS etc. Need to ensure quality of its functionality- are there guidelines and monitoring systems in place? Should provide must not replace – as far as possible- state budgetary funds. Should be utilised in time and accounted for. Should have a general direction – towards greater package of care, better quality of care and equity of access to care. Should be linked to measurable outcomes of rate of utilisation and quality and equity in care. What is the progress reported as of date?

10. Hospital development societies (Rogan Kalyan Samitis- RKS) Is RKS seen primarily as an alternative financing device or as improved management and outcomes vehicle. Composition of the RKS and processes of functioning: is it conducive to public/ community participation. Is there a composite expenditure planning which includes locally raised resources, untied fund grant and state budgetary support? Is it being used to plan to reach IPHS norms and quality standards? Is it equity sensitive? What are the monitoring mechanisms in place for state to know this. What is the progress reported as of date?

11. What is level of involvement of panchayats? In most statespanchayat standing committee members are involved in the District Health and Family Welfare Societies, Rogi Kalyan Samiti, the Village Health and Sanitation Committee (VHSC), selection of ASHAs (as well as certification of SC/ST/BPL families for JSY). Actual devolution of facilities to panchayats is a feature, only in West Bengal, Kerala and Nagaland. In states like Tripura and Tamil Nadu, the panchayat’s role was found to be proactive and very valuable. What are the plans in place for panchayat involvement?

12. NGO participation: Most NGOs while being appreciative of the NRHM maintained that the scope for NGO participation was very limited. In particular there was keenness on coordinating with the ASHA programme and other community processes, on assistance in ANM and dai training, and in BCC work. On the other hand there was widespread dissatisfaction in government divisions with the NGOs performance. What is NGO involvement in ASHA? What is progress of MNGO scheme? What are the other contracting arrangements made? What is involvement in BCC? What is the institutional framework to facilitate their involvement?

13. Reaching IPHS standards? What does facility survey show regarding inputs- infrastructure? How widely are IPHS standards known? What is the gap? In terms of service delivery? In terms of infrastructure? In terms of equipment ? In terms of supplies? In terms of human resources? What is the road map to achieve each of these? Are there any interim stage defined? Do supply side inputs to meet infrastructure and equipment and supplies gaps match the facility survey and the road map…

14. Emergency ambulance services as public-private/public-NGO partnerships are doing well in many states. In Andhra, Tamil Nadu and Gujarat with a toll free telephone number and a central control room they have had remarkable success. Could we replicate this in all states?

15. District Planning: “One major development of the NRHM is district level planning, which is complete or near complete in almost all states. Despite a mixed picture in terms of quality, it has brought various data together and made a basic skeleton of a plan which can be subsequently revised and built upon. However, the plans are yet to become documents that inform local health service development, programme implementation or community monitoring. Village plans prepared based on household health data and with involvement of PRIs are still an exception. “ What is the institutional framework for district planning and plan appraisal? How does one facilitate usage of plans to improve service delivery?

16. Integrated health societies; “Setting up of integrated State and District Health Societies with representation of all relevant departments is a step forward towards integration, and one that is found in all states. However complete integration between different divisions of the health department on financial management, monitoring and use of human resources is slow…” What needs to be done?

17. The Institutional Framework of programme implementation Programme management unit.\ including finanical management unit. Directorate of health services Infrastructure management unit Procurement corporation/cell Community participation/ASHA resource center. State institute of health and family welfare State health systems resource center. Clear role definitions and coordination mechanisms along with team building efforts should ensure that the conflicts between different structures of management are overcome.

18. In Improving Workforce Availability:the norms are defined Two ANMs per sub-center and one male worker per sub-center Three nurses per PHC and two medical officers. Nine nurses per CHC and 5 and more specialists per CHC. District hospital staff strength increases in nurses, technicians and in specialists..

19. Expanding available skilled human resource More medical colleges- government and private and through public private partnerships. More government seats in private medical colleges More nursing schools & nursing colleges. More technical and paramedical courses. Reviving ANM and MPW training centers.

20. Increasing availability in priority areas.. Compulsory rural postings- pre- post graduation – eg Orissa, Chhattisgarh and after graduation e.g. Tamil nadu Contractual appointments made to the facility- “contractual mode as a form of beating the pressure to transfer to urban areas– the residency criteria...” Eg Additional ANMs nurses in bihar, west bengal, tamil nadu etc. Eg specialists in madhya pradesh. fair transfer policy- rotational postings… tamil nadu.. Incentives for difficult areas: eg Himachal and Orissa. ‘Pooling’ of medical officers: West Bengal, Bihar, Jharkhand.

21. PPP options as HR solutions Contracting-in options. Madhya Pradesh for specialists: Contracting-out options. Arunachal Pradesh; of PHCs to Karuna trust.. Bihar: Of PHCs; of diagnostics, of district planning.. Gujarat: PHCs, CHCs and a district hospital.& CHIRANJEEVI: Punjab: village level dispensaries Sewa Mandir Rajasthan / Haryana maternity hut

22. Increasing availability of skilled in priority areas.. Multi-skilling existing staff to play more tasks. Medical officers to play specialist roles: emergency Ayush doctors for medical officer roles. Nurse practitioners to fill in for doctors Pharmacists providing curative care. Male multi purpose workers into male multi-skilled workers to provide a set of support services of the PHC. ANM schools in under-served areas.

23. Building road maps to increase availability- the West Bengal case study: Decision to appoint married woman, resident in that panchayat. All sub-centers co-located with gram panchayat. Selection by board under leadership of local panchayat. Selected and sent for training. Revised sub-center building with state putting up two thirds costs. Established 31 new training schools plus existing 18 under PPP arrangements where the state pays for the salary of the faculty to the private hospital. 3527 out of 10,000 needed are under training.

24. In Improving Workforce performance: Building a network of district, regional and state level training institutions led by the SIHFWs that ensures that the level of skills needed for service delivery at every facility and in every health programme are in place, is one of the most important areas of health sector reform that is urgently needed. Putting this in place at every level along with teams/centers for providing assistance and the institutional memory for district planning is another priority. Pre-service training institutions for generating multipurpose workers, both male and female, and their supervisory staff, which have gone into dysfunction in the last decade, need to be revived, expanded and strengthened. There needs to be a systematic examination of the compensation packages and incentives being provided to the various health service cadre, and the opportunities for advancement in their careers along with a fair transfer and posting policy. These are some of the most sensitive indicators of good governance and a system of measuring and rewarding these needs to be built up. Multi-skilling of doctors and nurses and para-medicals is needed as a general strategy to provide the skill mix for reaching service guarantees under current human resource constraints. Making available graded standard treatment guidelines and essential drug lists and formularies, which could guide the wide range of health care providers actually providing health care.

25. Other cross-cutting( systems) areas BCC programmes Financial Management. HMIS: systems.

26. Programme Issues RCH Disease control programmes Convergence areas: Nutrition and the ICDS, water and sanitation, school education, Addressing declining sex ratios.

27. E.g. Janini Suraksha Yojana: “The Janani Suraksha Yojana (JSY) is another visible and welcome component, but is challenged by the slow rate of growth in infrastructure and personnel to meet the demand generated by the shift to institutional deliveries.” This includes improved ASHA programmes; emergency referral transport system, 24*7 PHCs, FRU- CHCs, blood storage and blood banks, quality assurance systems, human resource planning, skill development etc…

28. 24*7 PHCs Is the choice made adequate – in scale and in distribution? Is the increase in nurse manpower planned for? Is the skills- building plan in place? Is the transport linkages in place? Are STGs in place? Is the monitoring system with appropriate indicators in place…

29. e.g.malaria control District and village planning; HR:Entomologists and epidemiologists and laboratory technicians and the male worker and the malaria link worker… Systems for flow of slides, consumables, reports. BCC. Panchayat involvement.

30. Monitoring and the log frame approach… Most outcomes will take longer. But are the states on track: Is the plan on sufficient scale and sufficient rate and on sufficient technical quality? Is the implementation of the plan as per what is envisaged – critical role of the logframe…what are the bottle-necks and can we intervene fast enough and accurately and competently enough.

31. Of accountability framework for the facilitation teams… States have to take steps- center can only provide funds, provide technical assistance and provide enabling policy framework, provide monitoring But facilitation is an active process. Should we ask that each facilitation team achieves at least 66% of the critical process steps in at least 66% of the states under its charge.. What is the level and process of engagement needed to achieve this..