Evaluation of NRHM in Karnataka

1. Evaluation of NRHM in Karnataka Project Update Presented to Principal Secretary, Department of Health and Family Welfare, GOK Presented by Dr R Balasubramaniam

2. Agenda • Introduction to the project • Background and Literature Study • NRHM Funds analysis • Exploratory analysis of financial and health indicators • Correlational analysis

3. Introduction • T o understand the planning and execution processes of NRHM in Karnataka • To understand the efficacy of allotment and flow of funds keeping the taluk as fundamental unit • To make policy suggestions for effective planning, allocation and utilization of funds for achieving goals of NRHM • Focus of the study • NRHM Fund Allocation, Structure and Design • NRHM’s Current Funding Allocation, its utilization, implementation, and its impact on Karnataka’s Health Indicators 3

4. Proposal • Phase I: NRHM Funds Allocation Structure and Design, current funding and utilization, implementation, and its impact on Karnataka’s Health Indicators • Phase 2: Field validation, stakeholder appraisal of NRHM’s planning processes at the local and regional level

5. Phase I • Study of existing planning and implementation processes • For identifying focus areas and prioritizing fund allocations • Study of current progress at the taluk level, • Health indicators, fund allocation and expenditure, status of physical infrastructure, human resources • What correlates with taluk health indicators? • Overall development status of the taluk • Funding allocated to that taluk • Physical infrastructure • Human resources • Community involvement • Certain combination of the above What is the optimum combination of inputs needed for improvement in health indicators at the taluka level? 5

6. Phase II • Understanding • Local NRHM related processes • NRHM’s planning, fund allocation and expenditures from the local perspective • Levels of community engagement, monitoring and ownership of public health systems • Validation and analysis of regional disparities. • Identification of local challenges and gaps. • Possible policy advocacy options obtained during this study 6

7. Background and Literature Study

8. Literature Review Outputs • Review of health policies • National Health Policy 2002 • State Health Policy 2004 • Report of the NCMH 2005 • Understanding NRHM • Review of evaluations and critiques of NRHM • Analysis of PIPs and DHAPs • Our impressions

9. Review of health policies National Health Policy 2002, Karnataka State Integrated Health Policy 2004, Report of NCMH 2005 • Documents the condition of the public health sector of the country • Recognize challenges in like • low quality of health indicators (especially RCH), widespread disparities (regional, rural-urban, gender, social groups) • low levels of public investment in health, • lack of accountability of the public health system and • under-utilization of public health infrastructure and services

10. Review of health policies • Suggest road-map and strategies • increase in public investment, the active role of centre • the involvement of PRIs in all stages • the emphasis on primary health care and particularly PHCs and SCs • the importance of women’s health • inter-sectoral approach (nutrition, sanitation, water supply) • Importance of planning and monitoring • HR reforms in the health sector

11. Understanding NRHM Objective: “…improving the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children”.

12. Evaluations of NRHM • NRHM - Meeting People's Health Needs in Partnership with States - The Journey So Far - 2005 – 2010 • Increase in spending on health has not reached intended targets*. (annual increase in NRHM overlay ~ 20% , annual increase in expenditure ~ 25%) • Planning efficiency, monitoring of expenditure to be improved • Mismatch between pace of increase in demand and availability of infrastructure • Problems of HR • Decentralization is slow, needs to be fostered. • Common Review Missions (Second and Fifth Rounds) • Karnataka is better off in terms of health finances (since multiple sources of funds exist). • Infrastructure is impressive (more than required according to IPHS). However, quality of works needs attention. • Shortage of HR • Frameworks, processes in place, but need to be strengthened. • Decentralization has created some friction. • Funds utilized, but not transformed into higher utilization rates. * Figures presented are at the national level.

13. Evaluations of NRHM • Report of the Working Group on NRHM for the Twelfth Five Year Plan (2012 – 2017) • Centre’s outlay on health has increased substantially. Together with this, state expenditure has also increased. • Karnataka lags significantly behind in IMR and MMR when compared to other southern states. May not achieve the targets with the current pace. • The largest share of NRHM funding has gone into infrastructure strengthening (31%) followed by RCH activities (28%) and disease control programmes (14%) • Funds released on ‘per facility normative basis’ and not responsive to utilization patterns leading to scarcity in some facilities and stagnant funds in others.

14. Evaluations of NRHM • Performance audit of NRHM (CAG, 2008) • Funds released to states on share of population, rather than on equity/need. • Guidelines not being followed in expenditure • Poor accounts and record keeping (also field experience) • Concerns of under-utilization of funds (James et al, 2009) (Gayithri et al, 2011) • Inadequate understanding of NRHM • Confusion over spending of Untied Funds • Mismatch between releases and expenditure

15. Evaluations of NRHM • Regional Disparities (Gayithri et al, 2011) • Allocation to districts based on population • Urban/rural/geographical/community/gender disparities (documented in many official documents) • Karnataka lags behind other southern states in terms of MMR (178) (SRS, 2009) • Kerala and TN have reached 100 • Estimated MMR of Karnataka in 2012: 130 • Health gains not in line with expenditure on infrastructure and activities

16. NRHM – Field experiences • NRHM has played a major role in • improving infrastructure • increasing the reach of health services in rural areas • increasing institutional deliveries • reducing mortality rates • improving the overall general health of pregnant women and new mothers

17. NRHM – Field experiences • Acute shortage of human resources • Issues in disbursal of funds in schemes like PA and JSY • Additional responsibilities: More time spent on documentation and logistics, reduced field time for field workers and MOs • Lack of proper documentation of fund position • Many PHCs, (some lack infrastructure, some are under-utilized), need more PHCs in some areas • Non-availability of drugs, extra charges for drugs • Mismatch in the planned and actual needs of the PHCs • Not many PHCs (and 24 X 7s) handle deliveries • True participation of VHSC and ARS in monitoring and management has a long way to go.

18. NRHM - PIP Preparation process • Every year, PIP is prepared based on GoI resource envelope. • Resource envelope: • Last year’s allocation + 10 – 15 % increase + state share • PIP template is given to PHCs, taluks and districts (changes every year) • Training, workshops have to be conducted • Teams are prepared for collecting information • Extensive information collected in the form of tables • PIPs are reviewed by the NPCC, revised and the ROP gives the final approval to the PIP

19. Observations on PIPs • Do not seem to indicate district specific needs and innovations • May not cover actual action/implementation fully • New hospitals constructed , mentioned in next year’s PIP, not matching with PIP of previous years (Infrastructure Strengthening 2008-09, 2009-10 PIPs) • Only in a couple of years, do we see plans integrated from other projects like KHSDRP • Too ambitious in health outcomes Karnataka State PIP, 2009 – 10, pp: 13

20. Analysis of DHAPs • DHAP is the corner stone of NRHM • considerable time and effort required to build decentralized planning capacities. • However, planning is not new, and in parallel, other planning activities are also going on. • Issues • A lot of data is collected and analysis of this data would give critical district specific information • Non-integration of different activities at the district level (w.r.t health itself as well as related sectors) • Needs and requirements mentioned in different sections of the DHAP are not integrated into the work plan section

21. Analysis of Sample DHAPs • Issues (Continued) • A lot of material is repeated and taken verbatim from other sources. Most of this does not add any new value. • There is no follow up on DHAP of previous year. • The DHAPs do not mention the analysis of readily available district data through HMIS • The work plans do not explicitly mention prioritization of issues • No discussion on issues related to drug procurement and disbursal (although it’s a recurring practical issue) • The FMR reduces DHAPs to a costing framework • Innovations are basically state-level innovations, rather than those borne out of district needs.

22. Our Impressions (based on literature review, analysis of PIPs and field experience) • Policies, mission documents, evaluations have clearly and comprehensively pointed out issues of concern. In actual planning and implementation, these concerns are not addressed. • Schemes are designed by top bureaucrats, activists and CBOs. Implementers of missions and schemes may not have internalized their objectives. Patterns of implementation haven’t change much at the ground level. • No valid benchmarks set in planning against which implementation activities can be evaluated. • Some indicators may not be sufficient to draw inferences (indicators on communitization) • Complex set of rules, guidelines and procedures (confusing both MOs as well as community) • Inefficiency and transaction costs continue to be significantly high

24. NRHM Funds Analysis • Methodology of analysis • Data sources • State level trends in • allocation and expenditure • status of health infrastructure • District trends • Correlational analysis • Regional imbalances

25. Exploratory analysis Methodology of funds analysis Customized expenditure heads • HR • Infrastructure and Maintenance • RCH Prog. Activities • NRHM Prog Activities • RI Prog Activities • Drugs • IEC and Training • Administration NRHM Heads of Accounts, 3 major heads (from Statement of Expenditure) • RCH Flexipool • NRHM Flexipool • RI About 300 line items (FMR) Remapped Progress: Done at the district level, for one year (2010-11) Not available for other years, not available at taluk level Correlational analysis Selected indicators from HMIS

26. Methodology of funds analysis • Exploratory analysis • Descriptive analysis of trends in financial and health indicators • Helps to identify un-natural and unexpected trends • Correlation analysis • Measures whether there is similarity in the trends of two or more variables. • Helps to identify whether the program expenditure is consistent with prior goals and objectives

27. Health and Finance Data Sources • NRHM HMIS • Various publications on the NRHM’s GOI and GOK websites • Progress of Programme publications • Dynamic reports from HMIS • District Level Household Survey 3 • PIPs, ROPs and DHAPs of various years • District Statement of Expenditures – 2010-11 (FMR) (taluk-wise details not available) • SHS audit reports

28. Differences and limitations in data • HMIS Data

29. Differences and limitations in data • IMR and MMR (HMIS data) • IMR in Karnataka - 38 (SRS Bulletin, Dec 2011) • MMR in Karnataka – 178 (SRS, 2009) IMR: ratio of the number of deaths of babies under one year of age per 1,000 live births MMR: ratio of the number of maternal deaths per 100,000 live births

30. Differences and limitations in data • These limitations (and no readily available taluk data) are addressed in the following ways: • Ratios and comparative trends (and not actual numbers considered wherever feasible) • Outliers not considered for state level analysis • Use various sources of data • Finance data

31. Analysis of NRHM in Karnataka • State government expenditure on health and family welfare since 2007 has increased annually by 19%. • GOI allocation and release under NRHM has shown an increased annually by 22% and 25% respectively. • State’s NRHM expenditure has increased annually by around 40% Karnataka Budget documents NRHM – Statewise Progress as on 31-03-2012, NRHM Facility Centre, MOH&FW, GOI

32. Analysis of NRHM in Karnataka • NRHM Flexipool is the major component, followed by RCH flexipool and infrastructure and maintenance grants (channeled through the revenue route) • Immunization funds form around 1%-2% of the total funds Approved ROPs (2007 – 2011)

33. Analysis of NRHM in Karnataka Releases and expenditure of the State Health Society from 2005-09 NRHM – Statewise Progress as on 31-03-2012, NRHM Facility Centre, MOH&FW, GOI 2010 and 2011 expenditure figures - provisional

34. District level trends in expenditure • Fund utilization levels at the district level has largely improved, (visible due to increasing absorption rates of NRHM flexipool funds. • Major allocation of funds is at the district level. • Overall funding pattern for districts relate to population (rather than rural population and health indicators) • Availability and timing of funds is not an issue at the district level. (Timing of fund releases within districts have to be verified in the second phase) • Funds released is usually higher than fund allotment • Districts with better health indicators seem to be spending more on infrastructure and maintenance (in their basket of allotment)

35. NRHM Statement of expenditures (2005-10)

36. Analysis of funds given to districts Health Ranks: Based on tables in situation analysis in State PIP – 2009-10 Population statistics: Census 2011 Funds received by districts: Yearly audit reports

37. Planning, fund availability and expenditures Total Fund Availability more than allocation (most expressed in RI)

38. Planning, fund availability and expenditures – RCH Flexipool

39. Planning, fund availability and expenditures – NRHM Flexipool

40. Planning, fund availability and expenditures – Routine Immunization

41. Districts with better health indicators seem to spend more available funds on infrastructure and maintenance

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44. 44

45. Regional Imbalances • Regional imbalances recorded and presented in great detail in numerous documents and reports • State health policy • HPCRRI report (Dr Nanjundappa Report) • Individual PIPs • However, fund allocations in PIPs and DHAPs are influenced by existing number of units

46. Mapping of PHCs in Karnataka Regional imbalances

47. Regional Imbalances • Districts with more than 50% of PHCs as 24 x 7s • Chamarajanagar • Tumkur • Kolar • Gulbarga • Bidar • Bijapur • Koppal • Dharwad • Bagalkot Rural Health Statistics 2011

48. Correlation analysis - 1 • Relationship between expenditures, existing infrastructure and Health Indicators • district-wise expenditure under major heads: RCH NRHM and RI, for all years between 2005 – 2011 • existing health infrastructure (2011) • district populations in 2011 (and population growth rates) • holistic health indicators (devised by National Commission on Population, GOI, 2001, used in 2008-09 state PIP to demonstrate regional imbalances) – serves as a guideline for regional prioritization

49. Correlation analysis - 1 • RCH expenditure is higher in regions with where health indicators are poor. • NRHM flexipool, Routine immunization and total funds in NRHM have not targeted the imbalance in health indicators. • Over-all expenditure is strongly and positively correlated with existing infrastructure (and not health indicators). • Expenditure is strongly and positively correlated with district populations. • Existing infrastructure does not have significant correlation with population (and is corroborated with the imbalance analysis) • Infrastructure does not have significant correlation with health indicators (however, there is a general –ve relationship) • SCs, PHCs, CHCs, Sub-divisional hospitals are also highly positively correlated with each other

50. Activities completed • Literature review • Background data collection • Macro-level data collection • Methodology for analysis (based on existing data) • District expenditure analysis • Formulation of financial indicators • Selection and formulation of health indicators from HMIS • Correlation analysis • Analysis of PIPs, DHAPs