RURAL HEALTH CARE MISSION GOI, MOFW
Item
- Title
- RURAL HEALTH CARE MISSION GOI, MOFW
- extracted text
-
RF_COM_H_92_SUDHA
Mission for Rural Health Care
Delivery in Selected States
Draft Document for Discussion
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Preamble
This Mission seeks to improve rural health care
delivery in states where it is weakest at present by
ensuring a provider in each village, effective
hospital care to the rural population and converged
action on health and the determinants of health for
maximum impact. The Mission will be the
instrument to integrate multiple vertical
programmes at the District level along with their
funds. The Mission will ensure the right of every
child in these states in India to basic health
services
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Current Situation
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_• I Health status of the people is extremely poor in
I the rural areas of the 10 states of Bihar, Jharkhand,
i Madhya Pradesh, Chattisgarh, Orissa, Rajasthan,
.
Uttar Pradesh, Uttaranchal, Assam. Jammu and
Kashmir and states in the North-East
• Poverty and ill-health are mutually reinforcing
• Status of public provisioning of health care weak
where it is needed most
• These states also contain the 150 population-focus
districts: New national response required
Current Situation
• Health Sector has not utilised opportunity for
intersectoral action provided by panchayat raj
* Health output dependent on action for health
combined with action on key determinants of
health like safe water, sanitation, nutrition etc.
Panchayat Raj has mandate also over these
determinants
• Opportunity to redesign ineffective national
programmes mandate in NCMP/PM9s directive to
revamp-delivery
4
Rural Health through a Citzen
Lens
“ Burden of disease high on account of poverty and
illiteracy”
“ There is no official health provider in the village”(in
most villages in these states )
“ There is a designated ANM( MPW). Located
elsewhere so visits, at best, twice a month”
“Most deliveries take place at home—the nearest PHC
(20 kms) anyway cant provide institutional care”
“The nearest effective unit for hospital care is the CHC,
about 40 kilometers away”
“ There are private providers close by whose services
are paid for”
5
Rural Health Care through
Government Lens
’ There is a Multi-Purpose Worker ( Male and Female)
for population of 3000-5000 at the Sub Centre as First
Unit
> The next unit is one for hospital care- Sector PHC for a
population of 30,000-1,00,000 ( about 40 villages) with
one doctor, one nursing assistant, one ward boy,
dresser, 2 sector supervisors and 2 MPW. It also has 6
beds
• There is a Community Health Centre for a population
of over 1 lakh. With over 10 doctors, nursing staff, lab
technicians, radiologists etc and about 40 plus beds.
High occupancy rate
6
Rural Health and Government
Provisioning: Why does it fail?
• First Unit of MPW ( ANM) fails because not a
resident of the village
; W'y..
• Second unit of PHC a planning failure of serious
proportions. Utilisation of beds 0 to 2%. A
mixed-up model combining inpatient care and
outreach function not doing either
• Means citizen gets effective referral care only at
CHC- about 40 Kms away
• Though private providers exist, there is no link
with them for public health
7
Rural Health and Government
Provisioning: Why does it fail?
• MPW ( ANM) is an extension of the government into
the village—not a 66finger of the community going up” therefore comes with government’s health agenda and
not structured to respond to people’s health needs
° Government does not simultaneously act on the causes
of ill-health ( preventive action on determinants)
& Private providers are not accredited and therefore do
an entrepreneurial function, not a public health one
• Government has u programmes for individual
diseases” and not a plan for comprehensive health care
° Health care delivery is completely top-down with
priorities set in Delhi and flowing down
8
Some serious planning errors/
need for correction
• ANM( MPW) conceived on population- norm and
needs to be based on habitation-norm
• Sub Centre has no autonomy
6 Sector PHC cannot do inpatient care and so needs
to be reconfigured as outreach unit only
• CHC can be strengthened to become first effective
referral unit
• District has no space to plan for itself—therefore
cant link effectively with determinants
9
Some serious planning errors/
need for correction
• No collective platform for health at district-level
which includes private providers, other non
allopathic providers
* State level budgets being spent mostly on salaries
and medicines, GOT has become the real player in
programme design—more so for poorer states
• Resource constraints and importance of health
goals have brought in large number of donors: in
the absence of an integrating framework donor■ catalysed programmes further fragment
comprehensive health care into” selective” goals
Some serious planning errors/
need for correction
• Within states, areas are carved out for different
donor agencies
• Each programme operates as a vertical silo
® Too many vertical programmes with no horizontal
connections
• Every programmes exhorts “intersectorality” but
in practice fragment resources and dissipate
energies
• In short health sector which needs “extra-sector
action” to be effective, is internally fragmented /' .
u
What could be done?
Step 1: Simple horizontal integration at the district
level of all vertical programmes under the format
of Rural Health Care Delivery Mission
• A “ funnel” approach to doing this: May be many
on top but flow into one common pool at district
level
• GO! will create one omnibus Centrally Sponsored
Programme called “ District Rural Health Care
Delivery Mission” and put under it the following
programmes
What could be done?
Programmes for integration of funds at district level
under the common head of the Mission:
(a) Strengthening of Rural Health Infrastructure (b)
Population Control © Reproductive and Child Health
(d) National Malaria Programme (e) National
Leprosy Eradication Programme (f) National Kala
Azar Programme (g) National Programme for
Control of Blindness (h) National Iodine Deficiency
Disorders programme (I) National Filaria
Programme (j) Revised National Tuberculosis
Programme
(b) National Aids Programme and National Cancer
Programme may be separately considered
j
•
What could be done?
(f) District Health Plan
* This plan should detail action under components
(a) to (e) and suggest collaborative action for
determinants through other sectors like safe water,
sanitation, nutrition etc.
• It could contain ideally an (g) untied fund for
supporting local action
• The District Health Society will have on it
intersectoral functionaries who can operationalise
such a plan
18
What could be done: Supportive
Action
• District Health Society will pool existing personnel
under different societies for managerial support: Gaps
here will be provided for( example, accounts staff)
* Private sector, NGO collaboration would be enabled at
district level through district health plans
• District Public Health Report will be presented each
year on status under key components
• Concurrent review will be done by non government
organisations
19
Mission Output
• At the village level, every village gets a provider—
either MPW or Community Health Activist
* At the village level, if possible, a health room
9 At the village level, a trained dai in each village
• At the village level, a sensitised frontline team of
panch,MPW,Anganwadi worker etc
• At village level, action on determinants of health
• At village ( cluster) level, a better functioning sub
Health Centre with untied funds for community
health action
20
Mission Output
8
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°
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9
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A better functioning CHC for hospital care
Each CHC working under community control, with local resource
mobilisation
At District level, a coordinated plan that links with private
providers
At District level, a coordinated plan with action on determinants
At District level, integration of resources internal to health sector
and combining with outside sector funds
At District level, effective support staff
At District level, effective programme review and public
accountability
Impact on IMR, MMR, Universal. Immunisation, Reduction in
Communicable Diseases in 4 years, mainstreaming Aids
prevention, leading to population stabilisation
21
Everybody wins
• Citizens get improved health services
• Local bodies/ District gets leadership roles in
planning for their area
• State governments/ state managers get freedom
-from vertical programmes that dissipate energies
• Government of India is able to target its resources
better and ensure better outcomes
• Private Sector, NGOs get space to collaborate
• Development Partners get value for money
22
Mission Implementation:
Structure ( for all Missions)
• Mission Coordinating Group headed by the Prime
Minister with Deputy Chairman Planning Commission,
Ministers of Mission areas, Cabinet Secretary and
Principal Secretary to PM.
s National Mission for Rural Health Care Delivery
located in the Ministry of Health (Family Welfare).
• Mission Steering Group headed by Minister of Health,
Secretaries of the three wings of health, Member
Planning Commission, Secretaries of WCD,
Elementary Education and Literacy,Experts. Mission
located in Department of Family Welfare with a
Mission Director ( at JS level)
Mission Implementation
• State level Missions headed by the Chief Minister
with similar composition
• State level Steering Group headed by the Chief
Secretary
* District level Mission with ZP as Chairperson,
Collector as Co-Chairperson and CMHO as
Secretary and heads of Committes for health,
education. WCD in ZP etc as members along with
district heads of Departments, representatives of
private providers, NGOs, experts on public health
1 Circulation of the draft Mission outline to a
selected group of experts and representatives of
states taken up under the Mission: 15-18
September
• Meeting to finalise Mission and setting deadlines
for state-level documents: 1st week of October
• Finalisation of National Mission Document: 15
October
• Cabinet Clearances etc 15-30 October
• Mission to commence: 14 November
25
Page 1 of 5
Con H - 3m■ 1
CHC
From:
To:
Sent:
Attach:
Subject:
"PHM-Secretariat" <secretariat@phmovement.org>
"Sundararaman" <sundar2@123india.com>; "Amit Sengupta" <ctddsf@vsnl.com>; "Jean
Dreze" <dreze@econdse.org>; <chaukhat@yahoo.com>; "Ritu Priya" <ritupriya@vsnl.com>;
"pha-ncc" <pha-ncc@yahoogroups.com>: "Jean Dreze" <j_dreze@hotmail.com>
Tuesday. October 05, 2004 5:13 PM
Strategy for 150 CMP districts.doc
[pha-ncc] Fw: Rural Health Mission
Greetings from PHM Secretariat (Global)'
While wc await Amit’s report about the 22nd September dialogue on Health with National Advisory
Council (Jayaprakash’s paper on Health Care). I am enclosing another document which has been
received by many of us (wc don’t know who arc the others on the invitation list as yet), about a
‘Mission for Rural Health Care Delivery in selected states’ - to be discussed at a meeting in Delhi
on 7th October organized by Sri Prasanna Hota (Health and Family Welfare secretary) in the
presence of the Health Minister. This is a Mission that is to be launched on 14^ November (why
the populist hurry9?).
Hope you have all seen the critiques and responses to Jayaprakash’s paper by .ISA, Sundar, JNIT
and CHC all of which have been circulated to continue to evolve a healthy consensus on inputs to
the Ministrv’s initiatives.
Any comments on this Rural mission may be sent before 7^" in ease you wish some of us to raise
the issue and also after as a continuing interactive dialogue. Just as wc were forwarding it, another
complimentary paper arrived m(scc below). On checking with the Ministry, the first paper is by the
PM’s office and the second one is by the Ministry (of Health Department of Family welfare)
Best wishes
Ravi Narayan
Attahcments:
a. Mission for Rural Health Care Delivery
b. Selected states - Draft document for Discussion from PMOs offic-i
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INSTITUTIONAL:
- Expanding the EAG mechanism to Rural Healthcare Mission (RHM) for focused
attention on 17 States- 8 EAG States (U.P., M.P., Bihar, Rajasthan, Orissa,
Jharkhand, Uttaranchal and Chhattisgarh), 7 North Eastern States (Assam,
Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland and Tripura),
Jammu & Kashmir and Sikkim
« 5 States to be covered under Common Minimum Programme (CMP) Strategy for
1 n/r /n i
Pape 2 of 5
focus on population stabilization
e 8 States to be covered under North East Health Mission (NEHM)
- Graded packages for varying needs, based on State ownership and articulation
= At national level, RHM to be presided over by PM/HFM
e At state level, RHM to be presided over by CM/State Health Minster
9 RHM to include agendas of the 3 Departments of Health, FW and AYUSH
INTRA & INTERSECTORAL CONVERGENCE:
e All vertical national health programmes and donor funds to converge at the
State District level
s Funds for civil works, drugs equipment, training management and IEC pooled
together into a District Health Fund for which a composite District Health Plan
shall be made
5 Creation of a District Health Development Agency (DHDA)
e District Health Plan to address issues of Health, Nutrition and sanitation
- Convergence of infrastructure, including manpower, of AYUSH at district and
sub district levels. AYUSH products/medicines to be promoted in Reproductive
& Child Health (RCH) Programme.
PROGRAMME AND FINANCIAL MANAGEMENT INPUTS:
- Engaging skilled professionals like CAs, MBAs and MIS specialists to strengthen
State Programme Management Unit (PMU) and District management unit (DMU)
e Creation of a National Health Resource Centre (NHRC) to provide Technical
Assistance at Gol/State level
e Introducing e-banking, GIS based MIS etc, for improved programme
management
s Formalizing strategy for timely procurement and appropriate logistics
arrangement at district and sub-district levels
COMMUNITY PARTICIPATION:
« Giving functional responsibilities and powers to the Panchayati Raj bodies for
planning and supervising discharge of public health duties
10/6/04
Page. 3 of 5
* Constitution of District, Block nnd Village Level Health Coimnitteos
? Raising - cadre of voluntary Accredited Social Health Activists (ASHA) at
village levels
- Convergence between Abltvl, AWW and ASHA —Anganwadi to be the hub of
health and nutrition activities in the village
- Creation of a Drag & Contraceptive depot at village level
- Providing Flexifund at panchayat/sub-centre/district level to enhance control over
local issues for health and family welfare.
STRFNGTTTF.NINfT PTTRT If’’ UFA I TIT INFRA QTRI TiPTITRF-
- Operationalising FRUs- al! CHCs and 500,o PHCs
• Addressing mismatch of manpower and equipments at health facilities
- Performance benchmarking of public health facilities
• Constitution of Health Committees empowered to levy user fee- Gol to contribute
matching share
- Overcome manpower deficiencies through engaging private doctors
- Depending on availability of Budget, options like second ANM at Sub-centre and
salary payment of MPW (Male) by Gol could be considered.
PUBLIC PRIVATE PARTNERSHIP FOR HEALTH:
. Social Marketing/ Social Franchising of services (sterilization, IUD insertion,
institutional deliver^', immunization) and products (contraceptives) through a
network of Sukhi Parivar Clinics
« Enhanced Quality Transaction Cost (QTC) for sterilization, IUD insertion and
institutional delivery to incentivise private participation
. Arranging soft loan from hanks for setting up/ lipgradation of FW Clinic
* Declaring income from family planning services income tax free
- Adding other RCH and curative sendees gradually, through Community
Insurance
10/6/04
Page. 4 of 5
Lmlumced trailsuction cos! hi CMP States to provide cjiialitY sendee
Introducing rpualitv protocols for family planning procedures
Widening tl: bnsket of c0iitrHccntivcs under
Jqtinnnl Fnmilv AVpIfnr^
PmcramiviR
" - • I- - —.........
Strnteg^’ to me rensc contribution of NSV in sterilization procedures
Provision of continuing Medical Education and hands on training for both public
and accredited orivate sector doctors
Setting un an Ombudsman at National/State level
Constituting Qua lily Assurance Committees at State/District level
Insurance cover for acceptors and service providers of sterilization services in
Government & accredited nrivate climes
Accreditation process and branding of public/private health facilities
Social audit by NGOs, PRIs- triangulated verification system
Inclusion of the subject of Reproductive Health in syllabi of Medical Education
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1CESS OUTCOMES:
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Welfare, AW JSH A nufrition.
Strengthening preventive and promotive care at community levels
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Improved system of referrals
Strengthened public health infrastructure — provision of Maintenance Fund
Accountability'' and responsiveness to elected Bodies of the community
Simplification of planning and implementation of Schemes of Health and Family
Welfare and Donor Pro°ranimes
Optimization of resources
Graded nackaf?es to cater to State specific unmet needs — health infrastructure in
VFHM and focus on population stabilization in CMP States
10/6/04
Paoc5 of 5
- Improved systemic capacity for programme implementation and fond flow
? Creation of health infrastructure in backward districts
- Improving access to family welfare services and healthcare in CMP districts
through Public-Private Partnership
e Quality assurance in public health programmes
- Increased utilization of public health infrastructure
- Extending financial risk protection to poor for health, and family welfare sendees
= Community financing for maintenance of public health infrastructure
IMPROVEMENT IN DEMOGRAPHIC INDICATORS:
s Raising level of universal immunization from 50% to 90%
- Improved Infant Mortality' Rate and Maternal Mortality Ratio through increased
institutional deliveries and focus on IMNCI and immunization
e Reduction in Total Fertility Rate to enable attainment of goals of National
Population Policy for 2010
- Early treatment of infectious diseases
10/6/04
Mission 1'or Rural Health Care Delivery in Selected .States
(Draft Document for Discussion)
Preamble:
This Mission seeks to improve rural health care delivery in states where, it is weakest at
present by ensuring a. provider in each village, effective, hospital care, to rural population
and converged action on health and the determinants of health for maximum impact The.
Mission will he the. instrument to integrate multiple vertical programmes at the District
level along with their funds The Mission will ensure right to every child in these states in
India to basic health services
Current Situation:
> Health Status of the neonle is the extremely poor in rural areas of the 10 states of
Bihar Jharkhand Madhya Pradesh Chattisgarh. Orissa. Rajsathan, Uttar Pradesh.
Uttaranchal Assam Jammu and Kashmir and the states of North East
> Poverty and ill-health are mutually reinforcing
> Status of public provisioning of health care weak where it is needed most
> These states also contain the 1 50 population-focus districts’ New national
response required
> Health Sector has not utilised opportunity for inter-sectoral action provided by
Panchavat Raj
> Health output dependent on action for health combined with action on key
determinants of health like safe- water, sanitation, nutrition etc., Panchayat Raj has
mandate also over these determinants
> Opportunity to redesign ineffective national programmes mandate in NCMP/PM’s
directive to revamp delivery
Rural Health through a Citizen T,cns
.
•
.
♦
*
♦
“Burden of disease high on account of poverty and illiteracy”
“There is no official health provider in the village” (in most villages in these
states)
“There is a designated ANM (MPW). Located elsewhere so visits, at best, twice, a
month”
“Most deliveries take, place at home - Nearest PHC (20Kms) anyway cant provide
institutional care”
“The nearest effective, unit for hospital care, is the CHC about 40 Kms awav
“There arc. private providers close by whose services arc paid for”
Rural Health through Government Lens
.
There is a Multi-purpose Worker (Male and Female) for population of 3000-5000
at the Sub Centre- as First Unit
The next7< ‘he one mr’lospital Care - Sector PHC for a population of
■ ' ' '7 • 1.00,COO (About 40 villages) with one. doctor, one nursing assistant, one
ward boy, dresser. 2 sector supervisors and 2 MPW It also has 6 beds
There is a Community Health Centre for a population of over 1 Lakh. With over
10 doctors, nursing staff lab technicians, radiologists etc., and about 40 plus beds.
High Occupancy rate
al Health and Government Provisioning: Why does it fail?
First Unit of MPW (ANM) fails because not a. resident of the. village
Second Unit of PHC a planning failure of serious proportions. Utilisation of beds
0 to 2% A mixed-up model combining inpatient care and outreach function not
doing either
Means citizen gets effective referral care, only at CHC-about 40 kms away
Though private providers exist, there is no link with them for Public health
MPW (ANM) is an extension of the government into the village - not a “finger of
the communitv going up’’ therefore comes with government’s health agenda and
not structured to respond to people’s health needs
Government does not simultaneously act on the causes of ill-health (preventive
action on determinants)
Private, providers are not accredited and therefore do an entrepreneurial function.
not a public health one
Government has “programmes for individual diseases’’ and not a plan for
comprehensive health care
Health Care delivery is completely top-down with priorities set in Delhi and
flowing down
nc serious planning crrors/nced for correction
ANM (MPW) conceived on population - norm and needs to be based on
habitation-norm
Sub Centre has no autonomy
Sector PHC cannot do impatient care and so needs to be- reconfigured as outreach
unit only
CHC can be strengthened to become, first effective referral unit only
District has no space- to plan for itself - therefore cant link effectively with
determinants
No collective platform for health at district-level which includes private
providers, other non allopathic providers
State, level budgets being spent mostly on salaries and medicines. GOI has
become the. real player in programme design - more so for poorer states
Resource constraints and importance of health goals have brought in large, number
of donors: in absence of an integrating framework donor-catalysed programmes
further fragment comprehensive health care into “selective” goals
Within States, areas arc carved out for different donor agencies
Each nroErammc one-rates as a vertical silo
.
•
•
e»
.
•
»
*
Too manv vertical programmes with no horizontal connections
Even- programme exhorts '‘intersectorality’' but in practice fragment resources
and dissipate energies
In short health sector which needs “extra-sector action” to be effective, is
intCiiially iragmented
ubuiu
uiini,.
Step 1: Simple horizontal integration at the district level of all vertical
programmes under the format of Rural Health Care Delivery Mission
A “funnel” approach to doing this' May be many on top but flow into one
common pool at district level
GOT will create on Omnibus Centrally Sponsored Programmed called “District
Rural Health Care Delivery Mission” and put under it the following programmes
Programmes for integration of funds at district level under the common head
o«*Li>c
a) Strengthening of Rural Health Infrastructure
ui Population control
c) Reproductive and Child Health
di National Malaria Programme
ei National Leprosy Eradication Programme
r> National Kala Azar Programme
si National Programmed for Control of Blindness
hi National Iodine Deficiency Disorders programme
ii National Eilaria Programme
ii Revised National Tubcrculosis Programme
National AIDS Programme and National Cancer Programme may he
scnaratclv considered
•
.
.
•
These different programmes will be budgeted under the common head and
resources passed on to districts through states
Monitoring would be done by the centre and states for which separate streams for
monitoring will be retained at Centre/State levels
This will mean dissolving the multiple societies that now exist for managing these
programmes into one common Health Society at the District level. Could be
chaired by the Chairperson ZP, with collector as Co-Chair and CMHO as
secretary Operation of cheque by any two
All of the above to be done by GDI
Step 2: District Health Plan as Programme Instrument and following
comnonents
a)
Provider in Each Village: Government provider mapping and filling up gaps
by training one person in each village as a barefoot doctor ( in those villages
where none exist)
Government to provide training, kit, link with the sub Health
Ccntrc/PHC. Shc/Hc entitled to practice as government certified
community health activist
b)
Facility: Government will try and provide a health room in each village (if
resources permit: this is not considered essential, especially in low -density
population villages)
*
c)
Every' untrained dai will he trained in each ■village (many have
already been trained)
Organisation
A Frontline team for health in each village with elected Panchayat,
AWT/Community health Activist, Dai/tcacher/anganwadi worker
d)
Support from Private providers
District to identify and register all private providers and link them effectively
with, public health provisioning
c) Strengthening Facilities at Suh Centre, PHC, CHC
> Untied fund of Rs. 5000 peryear as Community Health Action Fund to
ANMZMPW to catalyse frontline team for action on health and
determinants
> Sector PTTC given territorial responsibility and its medical staff deployed
with CHC, if state so wishes
> CTTC strengthened with community monitoring through Patients Welfare
Committee
> CTTC allowed to levy user charges, more for accountability (poor can be
exempted to avoid any such criticism that poor arc. being charged)
f)
District Health Plan
•
•
*
g)
This plan should detail action under components (a) to (c) and suggest
collaborative action for determinants through sectors like safe water,
sanitation, nutrition etc..
Tt could contain ideally an (g) untied fund for supporting local action
The District Health Society will have on it intersectoral functionaries who
can operationalise such a plan
What could he done: Supportive Action
4
.
.
.
•
District Health Societv will pool existing personnel under different
societies for managerial support; Gaps here will be provided for (example,
accounts staff)
Private Sector, NGO Collaboration would be enabled at district level
through district health plans
District Public Health report will be presented each year on status under
key components
Concurrent review will be done by non government organisations
Mission Output
•
*
•
•
■>
•
•
.
.
•
•
•
.
At the village level, every village gets a provider - either MPW or
Community Health Activist
At the Village level, if possible, a health room
At the Village level, a trained dai in each village.
At the Village level a sensitised frontline team of panchayat, MPW,
Anganwadi, etc.,
At the Vi llage, level, action on determinants of health
At Village, (cluster) level, a better functioning sub health centre with
untied funds for community health action
A better functioning CHC for hospital care.
Each CHC working under community control, with local resource
mobilisation
At district level, a coordinated plan that links with private providers
At district level, a coordinated plan with action on determinants
At District level, integration of resources internal to health sector and
combining with outside sector funds
At district level, effective support staff
At District level, effective programme review and public accountability
Impact on IMP., MMR, Universal Immunisation, Reduction in
Communicable, diseases in 4 years, mainstreaming AIDS prevention.
leading to population stabilisation.
Everybody Wins
•
♦
•
•
•
Citizens get improved health services
Local bodies / District gets leadership roles in planning for their area
State Governments/State managers get freedom from Vertical programmes
that dissipate energies
Government of India is able to target its resources better and ensure better
outcomes
Private Sector, NGOs get space to collaborate
Development partners get value for money
5
Structure (For all Missions)
.
•
.
•
♦
♦
Mission Coordinating Group headed by the Prime Minister with Deputy
Chairman Planning Commission, Ministers of Mission areas. Cabinet
Secretary and Principal Secretary to PM
National Mission for Rural Health Care. Delivery located in the. Ministrv of
Health ( Family Welfare)
Mission Steering Group headed by the Minister of Health Secretaries of the
three wings of Health. Member Planning Commission. Secretaries of WCD,
Elementary education and Literacy, Experts. Mission located in Department
of Family welfare with a Mission Director ( at IS level)
State, level Missions headed by the ChicfMinistcr with similar composition
State level Steering Group headed by the Chief Secretary
District level Mission with ZP as chairperson, Collector as Co-chairperson
and CMHO as Secretary and heads of Committees for health, education,
WCD in. ZP etc., as members along with district heads of Departments,
representatives of private providers. NGOs, Experts on public health etc.,
Next Steps:
•
•
•
•
.
Circulation of the. draft. Mission outline to a selected group of experts and
representatives of states taken up under the Mission: 1 5-18 September
Meeting to finalise Mission and setting deadlines for state-level documents: 1st
week of October
Finalisation of the. National Mission Document ■ 15 October
Cabinet. Clearances etc.: 15-30 October
Mission to commence : 14 November
6
Cvrv)
Executive Brief
“Mission for rural health care delivery”
Goal:
To improve rural health care delivery in selected states ( Namely Bihar,
Jharkhand, MP, Chhattisgarh, UP , Uttranchal, Orissa, Assam, J&K, and
states in North East region).
Rationale:
Health care system is weak in these states. These stases cover 150
special focus districts.
Strategies:
Horizontal integration of all vertical programmes at the
district under one common centrally sponsored programme, “
District Health Care Delivery mission”.
1.
Common budget head for programmes for strengthening rural
infrastructure, population control, Reproductive and child health,
malaria, leprosy, blindness, iodine deficiency, filarial and
tuberculosis.
Management of he programme through one common health
society at the district.
2.
Development of district health plan to ensure
-
-
-
Health service provider at each village ( Government health
staff, Training local volunteer to act as “Bare Foot doctor")
Health room in each village
Training of untrained dais
Health team in each village comprising of elected Panch,
ANM/ Community volunteer, Dai, Teacher, Anganwari
worker.
Identifying qualified private service providers in the district
and linking them to government service provider.
Strengthening of CHC, PHC, SC.
User charges for services at CHC for those who can afford
Monitoring of services of CHC through patient Welfare
Committee.
1
, 3 C| .3
3.
Operationalisation of district health plan
Through District Health Societies
4.
Monitoring of plan
-
Concurrent review by NGOs
Annual review of district report on key indicators
Organisational structure:
1.
Centre
i.
Mission co-ordination group
Headed by Prime Minister, Deputy Chairman planning
commission, Ministers of related areas, Cabinet secretary,
Principal secretary to Prime Minister.
ii.
National Mission for rural health care delivery located
at Ministry of health & family welfare
iii.
Mission steering group
Headed by Minster of Health & Family Welfare,
secretaries of three wings of health, member planning
commission,
secretaries
of
women
and
child
development, elementary education and literacy, experts
2.
State
i.
State level Mission
Headed by Chief Minister, head state planning unit,
Ministers of related areas etc.
ii.
State Steering group
Headed by chief secretary
2
iii.
District level group
Headed by chairperson of Zilla Parishad, co-chairperson
collector, secretary Chief medical officer, district heads of
other related departments, representatives from NGOs,
Private practitioners and public health experts.
Time frame:
i.
Meeting to finalize mission document and setting deadlines for state
level mission documents
By
7th
October 2004
ii.
Finalization of National Mission document
2004
By
iii.
Cabinet clearance
2004
By 15-30th October
iv.
Mission to commence
2004
On 15th November
3
15th
October
Discussion points on the mission
1.
Do you think this mission is useful and relevant to your state, if yes
give justification and if no why?
2.
Please consider your state and identify what are strengths and
weakness in your health services to implement this mission in your
state.
2.
What changes you would suggest in the mission document for its
successful implementation?
3.
Any other remarks
4
OVERVIEW OF RURAL HEALTHCARE MISSION
STRA TEGIC INPUTS
INSTITUTIONAL:
•
•
•
™
°
•
•
•
Expanding the EAG mechanism to Rural Healthcare Mission (RUM) for
focused attention on 17 Stales- 8 EAG Stales (U.P., M.P., Bihar, Rajasthan,
Orissa, Jharkhand, Uttaranchal and Chhattisgarh), 7 North Eastern Slates
(Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland and
Tripura), Jammu & Kashmir and Sikkim
5 States to be covered under Common Minimum Programme (CMP)
Strategy for focus on population stabilization
8 States to be covered under North East Health Mission (NEI IM)
Graded packages for varying needs, based on State ownership and
articulation
At national level, RJIM to be presided over by PM/HFM
At state level, RHM to be presided over by CM/Statc 11 cal th M ins (er
Rl IM to include agendas of the 3 Departments of 1 leal th, FW and A YUS 11
INTRA & INTERSECTORAL CONVERGENCE:
All vertical national health programmes and donor.funds lo converge al the
Statc/District level
• Funds for civil works, drugs equipment, training management and IEC
pooled together into a District Health Fund for which a composite District
Health Plan shall be made
• Creation of a District Health Development Agency (DUDA)
• District Health Plan to address issues of Health, Nutrition and sanitation
• Convergence of infrastructure, including manpower, of AYUSH at district
and sub district levels. AYUSH products/medicines to be promoted in
Reproductive & Child Health (RCH) Programme.
•
f
PROGRAMME AND FINANCIAL MANAGEMENT INPUTS:
•
Engaging skilled professionals like CAs, MBAs and MIS specialists to
strengthen State Programme Management Unit (PMU) and District
management unit (DMU)
•
•
Creation of a National Health Resource Centre (NHRC) to provide
Technical Assistance at Gol/Statc level
Introducing c-banking. GIS based MIS etc, for improved programme
management
•
formalizing strategy for timely procurement and appropriate logistics
arrangement at district and sub-district levels
COMMUNITY PARTICIPATION:
Giving functional responsibilities and powers to (he Panchayati Raj bodies
for planning and supervising discharge of public health duties
» Constitution of District, Block and Village Level Health Committees
• Raising a cadre of voluntary Accredited Social Health Activists (ASHA) at
village levels
• Convergence between ANM, AWW and ASHA -Anganwadi to be (he hub
of health and nutrition activities in the village
• Creation of a Drug & Contraceptive depot at village level
» Providing Flexifund at panchayat/sub-centrc/district level to enhance control
over local issues for health and family welfare.
•
STRENGTHENING PUBLIC HEALTH INFRASTRUCTURE:
•
•
»
•
•
•
W
Operationalising FRUs- all CHCs and 50% I’HCs
Addressing mismatch of manpower and equipments at health facilities
Performance benchmarking of public health facilities
Constitution of Health Committees empowered to levy user fee- Gol to
contribute matching share
Overcome manpower deficiencies through engaging private doctors
Depending on availability of Budget, options like second ANM at Subcentre and salary payment of MPW (Male) by Gol could be considered.
PUBLIC PRIVATE PARTNERSHIP FOR HEALTH:
•
•
•
Social Marketing/ Social Franchising of services (sterilization, IUD
insertion, institutional delivery. immunization) and products (contraceptives)
through a network ofSukhi Parivar Clinics
Enhanced Quality Transaction Cost (QTC) for sterilization, IUD insertion
and institutional delivers' to incentivise private participation
Arranging sol) loan from banks for setting up' upgradation of FW Clinic
2
•
•
Declaring income from family planning sen ices income tax free
Adding other RCll and curative services gradually, through Community
Insurance
QUALITY CONTROL;
•
•
•
•
•
a
°
»
•
•
•
•
Enhanced transaction cost in CMP States to provide quality service
Introducing quality protocols for family planning procedures
Widening the basket of contraceptives under National Family Welfare
Programme
Strategy to increase contribution of NSV in sterilization procedures
Provision of continuing Medical Education and hands on training for both
public and accredited private sector doctors
Setting up an Ombudsman at Nat ional/S late level
Constituting Quality Assurance Committees at Statc/District level
Insurance cover for acceptors and service providers of sterilization services
in Government & accredited private clinics
Accreditation process and branding of public/priv ale health facilities
Social audit by NGOs, PKIs- triangulated vetiI'ication system
Inclusion of the subject of Reproductive Health in syllabi of Medical
Education
A
OUTPUTS OF THE RURAL HEALTH MISSION
PROCESS OUTCOMES:
Decentralization and convergence at vi 11 age/di strict levels for Health, Family
Welfare, A-YUSH & nutrition
••• Strengthening preventive and promotivc care at community levels
Improved system of referrals
Strengthened public health infrastructure - provision of Maintenance Fund
••• Accountability and responsiveness to elected Bodies of the community
Simplification of planning and implementation of Schemes of Health and
Family Welfare and Donor Programmes
Optimization of resources
Graded packages to cater to State specific unmet needs - health
infrastructure in NEHM and focus on population stabilization in CMP Stales
b <• Improved systemic capacity for programme implementation and fund flow
Creation of health infrastructure in backward districts
Improving access to family welfare services and healthcare in CMP districts
through Public-Private Partnership
•P Quality assurance in public health programmes
•? Increased utilization of public health infrastructure
Extending financial risk protection to poor for health and family welfare
sendees
'
Community financing for maintenance of public health infrastructure
MPROVEMENT IN DEMOGRAPHIC INDICATORS:
Raising level of universal immunization from 50% to 90%
Improved Infant Mortality Rate and Maternal Mortality Ratio through
increased institutional deliveries and focus on 1MNCI and immunization
<• Reduction in Total Fertility Rate to enable attainment of goals of National
Population Policy for 2010
•< Early treatment of infectious diseases
_ t
I '
4
Page 1 of 5
PHM-Secretariat
From:
To:
Sent:
Subject:
"sushama rath" <sushamarath@yahoo.co.in>
<secretariat@phmovernent.org>
Tuesday, October 05, 2004 3:12 PM
Rural Health Mission
Co
H. -
Dear Sir,
As already informed in the invitation letter TA/DA will paid to you including air travel by economy
class.
Overview of Rural Health Care Mission is hereby sent.
Sushama Rath
Under Secretary' (ID/EAG)
OVERVIEW OF RURAL HEALTHCARE MISSION
SIRA TEGIC INPUTS
INSTITUTIONAL.-
• Expanding the EAG mechanism to Rural Healthcare Mission (RUM) for focused
attention on 17 States- 8 EAG States (U.P., M.P., Bihar, Rajasthan, Orissa,
Jharkhand, Uttaranchal and Chhattisgarh), 7 North Eastern States (Assam,
Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland and Tripura), Jammu
& Kashmir and Sikkim
• 5 States to be covered under Common Minimum Programme (CMP) Strategy for
focus on population stabilization
• 8 States to be covered under North East Elealth Mission (NEHM)
• Graded packages for varying needs, based on State ownership and articulation
• At national level, RHM to be presided over by PM/HFM
• At state level, RHM to be presided over by CM/State Elealth Minster
• RHM to include agendas of the 3 Departments of Health, FW and AYUSFI
INTRA & INTERSECTORAL CONVERGENCE:
• All vertical national health programmes and donor funds to converge at the
State/District level
10/5/04
Page 2 of 5
• Funds for civil works, drugs equipment, training management and IEC pooled
together into a District Health Fund for which a composite District Health Plan
shall be made
• Creation of a District Health Development Agency (DHDA)
• District Health Plan to address issues of Health, Nutrition and sanitation
• Convergence of infrastructure, including manpower, of AYUSH at district and sub
district levels. AYUSH products/medicines to be promoted in Reproductive &
Child Health (RCH) Programme.
PROGRAMME AND FINANCIAL MANAGEMENT INPUTS:
• Engaging skilled professionals like CAs, MBAs and MIS specialists to strengthen
State Programme Management Unit (PMU) and District management unit (DMU)
• Creation of a National Health Resource Centre (NHRC) to provide Technical
Assistance at Gol/State level
• Introducing e-banking, GIS based MIS etc, for improved programme management
• Formalizing strategy for timely procurement and appropriate logistics arrangement
at district and sub-district levels
COMMUNITY PARTICIPATION:
• Giving functional responsibilities and powers to the Panchayati Raj bodies for
planning and supervising discharge of public health duties
• Constitution of District, Block and Village Level Health Committees
• Raising a cadre of voluntary Accredited Social Health Activists (ASHA) at village
levels
• Convergence between ANM, AWW and ASHA -Anganwadi to be the hub of
health and nutrition activities in the village
■ Creation of a Drug & Contraceptive depot at village level
• Providing Flexifund at panchayat/sub-centre/district level to enhance control over
local issues for health and family welfare.
STRENGTHENING PUBLIC HEALTH INFRASTRUCTURE:
• Operationalising FRUs- all CHCs and 50% PFICs
. Addressing mismatch of manpower and equipments at health facilities
10/5/04
Page 3 of 5
• Performance benchmarking of public health facilities
• Constitution of Health Committees empowered to levy user fee- Go! to contribute
matching share
• Overcome manpower deficiencies through engaging private doctors
• Depending on availability of Budget, options like second ANM at Sub-centre and
salary payment of MPW (Male) by Gol could be considered.
PUBLIC PRIVATE PARTNERSHIP FOR HEALTH:
• Social Marketing/ Social Franchising of services (sterilization, IUD insertion,
institutional delivery, immunization) and products (contraceptives) through a
network of Sukhi Parivar Clinics
• Enhanced Quality Transaction Cost (QTC) for sterilization, IUD insertion and
institutional delivery to incentivise private participation
• Arranging soft loan from banks for setting up/ upgradation of FW Clinic
• Declaring income from family planning services income tax free
• Adding other RCH and curative services gradually, through Community Insurance
QUALITY CONTROL:
• Enhanced transaction cost in CMP States to provide quality service
• Introducing quality protocols for family planning procedures
• Widening the basket of contraceptives under National Family Welfare Programme
• Strategy to increase contribution of NSV in sterilization procedures
• Provision of continuing Medical Education and hands on training for both public
and accredited private sector doctors
• Setting up an Ombudsman at National/State level
• Constituting Quality Assurance Committees at State/District level
• Insurance cover for acceptors and service providers of sterilization services in
Government & accredited private clinics
. Accreditation process and branding of public/private health facilities
• Social audit by NGOs, PRIs- triangulated verification system
10/5/04
Page 4 of 5
• Inclusion of the subject of Reproductive Health in syllabi of Medical Education
OUTPUTS OF THE RURAL HEALTH MISSION
. PROCESS OUTCOMES:
• Decentralization and convergence at village/district levels for Health, Family
Welfare, AYUSH & nutrition
• Strengthening preventive and promotive care at community levels
• Improved system of referrals
• Strengthened public health infrastructure - provision of Maintenance Fund
• Accountability and responsiveness to elected Bodies of the community
• Simplification of planning and implementation of Schemes of Health and Family
Welfare and Donor Programmes
• Optimization of resources
• Graded packages to cater to State specific unmet needs - health infrastructure in
NEHM and focus on population stabilization in CMP States
• Improved systemic capacity for programme implementation and fund flow
• Creation of health infrastructure in backward districts
• Improving access to family welfare services and healthcare in CMP districts
through Public-Private Partnership
• Quality assurance in public health programmes
• Increased utilization of public health infrastructure
• Extending financial risk protection to poor for health and family welfare services
. Community financing for maintenance of public health infrastructure
IMPROVEMENT IN DEMOGRAPHIC INDICATORS:
• Raising level of universal immunization from 50% to 90%
. Improved Infant Mortality Rate and Maternal Mortality Ratio through increased
institutional deliveries and focus on IMNCI and immunization
. Reduction in Total Fertility Rate to enable attainment of goals of National
Population Policy for 2010
10/5/04
Page 5 of 5
• Early treatment of infectious diseases
Yahoo! India Matrimony: Find your life partner online
10/5/04
Page 1 of 1
PHIV1-Secretariat
From:
To:
Cc:
Sent:
Attach:
Subject:
<dreze@econdse.org>
<chaukhat@yahoo.com>; <secretariat@phmovement.org>
<pha-ncc@yahoogroups.com>
Monday, September 20, 2004 3 00 PM
Strategyin150CMPdistricts-revised[1] doc
[pha-ncc] CMP for real
Vandana: You must have seen this but just in case (words in bold are mine). One could not hope for
a clearer statement of what is cooking,
Jean
Yahoo! Groups Sponsor
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10/5/04
Ccj
H'
*2>l-
Government of India
Ministry of Health and Family Welfare
Department of Family Welfare
STRATEGY IN 150 CMP DISTRICTS
FOR FAMILY PLANNING
The Common Minimum Programme (CMP) of the United Progressive CMP Mandate
Alliance (UPA) Government states that “the UPA Government is committed to
replicating all over the country the success that some Southern and other States
have had in family planning. A sharply targeted Population Control Programme
will be launched in the 150 odd high fertility districts”. The Department of
Family Welfare is initiating a CMP Programme accordingly in the identified 150
high fertility districts of the country. The strategy of the Department for the CMP
Programme is as follows:
The districts were arranged in descending order of Total Fertility Rate
(TFR) as per the Census 2001 data. By excluding better performing States with
one or two districts from the list, like Haryana (Gurgaon), Uttaranchal (Hardwar),
West Bengal (Uttar Dinajpur, Maldah), Gujarat (Dohad, Banas Kantha),
Chhattisgarh (Sarguja) and Assam (Dhubri, Goalpara, Marigaon), a list of 150
districts has been arrived at. These districts belonging to the better off States will
be taken care of by improved attention of the concerned States. These 150
districts are concentrated in the 5 EAG States of Bihar (36), U.P. (58), M.P. (24),
Rajasthan (20) and Jharkhand (12), as at Annexure-I. However, since it would be
administratively inconvenient to limit the proposed initiatives to select districts
within the State, it is proposed to cover all 209 districts in the 5 CMP States
under the new Strategy.
The National Population Policy aims at achieving a National Total
Fertility Rate (TFR) of 2.1 by 2010. It would still take another 35 years for the
population to stabilize by 2045 at the expected level of 160 crore. However, the
present trends indicate that if the present pace of reduction in growth rate
continues, the TFR of 2.1 may at best, be attained by 2016. The population may
touch 180 crore before stabilizing. It is, therefore, important to adopt strategy for
addressing the high order births (above two children per family) in the identified
high fertility districts, at a scale which will prevent at least 40 crore additional
births by 2045 permitting the country’s population to stabilize after peaking at
about 135 crores. The plans arrived through Community Needs Assessment
Approach (CNAA) in these districts also reflect a high level of unmet needs,
basically due to /.weak service delivery mechanisms/’ Of the total 48 lakh
sterilizations being reported in country, only around 13 lakhs are being reported in
the CMP States where as their high order births in these States are in the range of
93 lakhs per annum (of the total 170 lakh high order births in the country). It is
hoped to raise the level of sterilizations in these CMP States to 50 lakh per
annum within the next four years. In fact, we should thereafter increase the
scope of our programme and add another 150 high fertility districts to really
Selection of
Districts
tackle the unwanted births all across the country. It is also a fact that against
the average annual growth rate of population of 1.7% in rural India, the same is
2.7% for urban India and 4% for urban slums. The high growth rate in urban
slums is also largely due to the factor of immigration of BPL labour and families
from high fertility and poor districts to urban areas, especially the metros. It
would therefore be necessary to cover the urban slum pockets in the CMP
strategy. Then only the systematic prevention of 40 crore unwanted births will
actually happen.
Over the last 5 decades, the performance of the Family Welfare
Programme has been distinctly better in the Southern States like Kerala, Tamil
Nadu, and Karnataka as against the CMP Stales. Higher levels of literacy and
women empowerment in these States contributed to the success of the
programme. However, improved performance levels in these States also owe
largely to the political will, administrative commitment and good governance
in these States. A major lesson to be learnt from the Southern States is their
success in involving the private sector in service delivery. In the State of
Tamil Nadu, of the total 4 lakh sterilization being reported per annum, 1.5 lakh
procedures are being reported through the private sector. In the State of Andhra
Pradesh, the spectacular success in bringing down the growth rate of population in
the last decade has been possible, despite the low level of literacy, due to the
involvement of private sector and Self Help Groups, provision of insurance cover
to family planning acceptors, and a higher Compensation package for sterilization
in the State. Strong monitoring and the supervisory mechanisms in the Southern
States have ensured better accountability of the service providers. Under the
CMP Strategy, the lessons from the Southern States would be replicated in
select States of U.P., M.P., Bihar, Rajasthan and Jharkhand.
The Thrust Areas in these districts would be family planning,
immunization and safe delivery. Letters have been sent to Chief Ministers, Chief
Secretaries and Secretaries (FW) of the selected States, and also to District
Collectors of 150 CMP districts. Copies of the letters are enclosed at Annexures
II, III & IV. The strategy aims at bringing back the District Administration
into the Family Planning Programme. Detailed CMP Manual is being prepared
for the District Collectors of the CMP districts, to provide them with a roadmap
and suggested strategy. National/Regional Consultations with State Governments
and District Magistrates of 150 CMP districts shall be held.
The emphasis would be on targeting unmet need for family planning
services in these districts. Additional funds would be provided for improved
services for sterilization and IUD insertion. The Compensation package for
sterilization is being revised, to adequately over the transaction costs of the
procedures in public and private health facilities. Additionally, an imprest fund of
Rs. 10 lakhs would be provided to District Administration as a revolving fund for
family planning. Professional Indemnity Insurance cover shall be extended to
doctors conducting sterilization operations in both public sector and
accredited private health facilities, so as to cover them against legal and
financial costs of possible consumer cases. Detailed assessment of the
requirement of drugs, equipments, contraceptives and laparoscopes is being done
Lessons from
Southern States
Strategy in
CMP Districts
Emphasis on
Family Planning
services
for CMP districts, and a strategy shall be formalized for timely procurement and
appropriate logistics arrangements.
Partnerships with the private sector through accreditation, indemnity partnership with
insurance coverage and suitable higher payment nearer to basic market cost are Private Sector
the major hope for attainment of the goals in the CMP districts. A revised
Compensation package is being extended to accredited private/NGO health
facilities for conducting sterilization/IUD insertion. A package of around Rs. 1200
for sterilization in a private nursing home and Rs.600 in public health facility,
inclusive of transactional cost to the Trained Birth Attendant (TBA), and the
client to cover the expenses on travel, food, and access to the public/private
hospitals for sterilization will energize the demand and supply chain in family
planning. Availability of family planning services is thus hoped to increase
through social marketing and social franchise of such services. It is aimed to
provide quality assurance among such accredited facilities and to provide them
with a logo so as to generate publicity of the availability of such family planning
services in the private sector. Accrediting 15 to 20 private providers per
district is an attainable task. Banks are being approached to announce a special
package of loan of Rs.5 lakhs to Rs. 10 lakhs to these accredited doctors in CMP
districts to improve their infrastructure, space, equipment, Operation Theatre etc.
These loans will be viable as an accredited clinic is expected to earn at least
Rs.25,000 to Rs.30,000 extra per month and so repayment of the loan will be
possible. This itself is likely to help achieve 25-35% extra family planning
procedure. In Tamil Nadu, an average 30 to 40 private facilities have been
accredited per district. In spite of a well functioning governmental system and low
levels of fertility, 35% of all sterilization in the State are at accredited private
clinics.
The National Maternity Benefit Scheme is being revised as the proposed
Promotion of
Janani Suraksha Yojana (JSY), with the aim of promotion of institutional delivery maternal healthcare
to bring down the high Maternal Mortality Rate (MMR) in these districts
(Annexure-V). It is hoped that the JSY would prevent female foeticide through
raising consciousness for the girl child. It is aimed to provide an amount of
Rs.lOOO/girl child and Rs.400/male child, if delivered in a health institution,
by a BPL mother. Additionally, transport assistance upto Rs. 150, and incentive
to Dais @ Rs.200/150 for female/male child is also envisaged in lieu of
appropriate antenatal and postnatal care and referral for institutional delivery.
The scheme also aims at adoption of tubectomy by the pregnant women after the
delivery. It is aimed to operationalize First Referral Units (FRUs) at district levels
to ensure 24-hour service delivery for improved healthcare. Emphasis is also
being laid on provision of health infrastructure in urban slums.
It is proposed to engage around 2.6 lakh Trained Birth Attendants
(TBAs) at the rate of one per 500-1500 population aiming at one TBA for
village under one AWW in the CMP States as the grass root level worker
for the FW programme. The TBA would be the key to social mobilization in
these districts. She would be recruited by the AWW, in consultation with the
Women Self Help Group of the village, on payment of an honorarium of Rs.
100/- per month only. The ANM will countersign and confirm this appointment.
Engagement of
TBAs
3
The TBA will get 1EC material and other support from District Health
administration through the ANM. She will counsel the village women for
adopting contraception, safe delivery and institutional delivery. She would also
escort the client to the hospital, whether to a public or an accredited private
facility, for family planning and institutional deliveries and be paid a transaction
cost for each such procedure. She will also mobilize the children and expectant
mothers on immunization days. She is expected to earn Rs. 7500 to Rs. 8000 per
annum from her work. Additionally, she will be given products such as basic
medicines, contraceptives and ORS etc. for social marketing in the village. She
will also counsel for newborn care, breast feeding and adolescent hygiene and age
of marriage. She will assist in registration of births. All these, she will do under
the supervision of AWW and ANM among the women/girls of the community
where she normally resides.
Efforts shall also be made in these districts for improved immunization,
including strengthening of cold-chain, induction of Auto Disposable Syringes and
holding of Immunization Sessions on fixed days at village/habitation level, in
convergence with the ICDS workers. A major strategy is to make the vaccine
reach the immunization site on Vaccination Day so that the ANM can carry out
longer sessions. It is proposed to bring in legislation to make it mandatory for all
medical establishments, whether public or private, to render immunization
services. Medium-term Plan for strengthening of Immunization has been moved
to World Bank through Department of Expenditure. Copy of the same is enclosed
at Annexure-VI.
The work in the CMP districts is proposed to be undertaken in a Mission
mode. This would necessitate organizational restructuring of the Department of
Family Welfare at the Gol level, and setting up of a National Resource Centre for
providing Technical Assistance under different components of the Reproductive
& Child Health Programme. It is also proposed to upgrade the management
capacities at State and district levels for consolidation of the Programme
Management Units through induction of key skilled professionals like MBAs,
CAs, Inter Costs, MIS Specialists etc. under the leadership of an additional IAS
Officer as Executive Director, SCOVA at State level, and ex-service men at
district levels, to steer the programme. The strengthening of the financial and
programme management would be a key input of the envisaged programme.
Improvement of financial flows, improvement in accountability through better
maintenance of accounts by induction of professional financial personnel, and use
of e-technology to handle the huge number of transactions and sites efficiently is
the management key to the CMP strategy.
Strengthening
Immunization
Programme
Management
Strengthening
A programme-specific IEC campaign shall be launched for the CMP
Improved
districts, including wall writings, hoardings, posters, brochures, CDs and briefing convergence, publicity
kit for various stakeholders, informing the key players of the new initiatives and
and programme
monitoring
the public-private institutions partnering in this activity.
Intersectoral
convergence with related Departments would be strengthened and involvement of
members of Panchayati Raj Institutions and Self Help Groups stressed to make
the programme a people’s programme. The monitoring of the Family Welfare
Programme shall be improved through e-linking with video-conferencing in CMP
4
districts and with the 5 EAG States’ Secretaries. We also propose to use etechnology for social auditing, consumer suggestion/grievance monitoring,
handling fund flow and other related issues. A concept note on the subject is
enclosed at Annexure-VII.
Detailed costing has been done of all the additional activities proposed
above. The Department of Family Welfare is of the view that it should be
possible to undertake the additional activities in the current year by regrouping
funds available under different Budget Heads of the Department. It should also be
possible to accommodate the additional financial requirements for the remaining
period of the 10th Plan within the Budget of the Department, if the officially
indicated Outlays for the 10,h Plan are fully funded. This would, however, require
some intersectoral adjustments within the Budget Heads of this Department, for
which orders of competent authorities would be obtained. It is possible to
continue funding these new initiatives not only in these 150 CMP districts, but
also in additional 100 to 150 districts in the 11th Plan with only a normal increase
in the Budget, by 50%. The Common Minimum Programme already states that
over a period, the Health Budget would be doubled. Also, from 9th Plan to 10th
Plan, our Budget increased by 80%. We are thus looking at a very practical
financial plan. The savings to the country, by way of avoiding 40 crore
unwanted births would be far more.
Financial
Implications
5
Go
W -
G
Mandate of the National Common
Minimum Programme (NCMP)
OVERVIEW OF
RURAL HEALTHCARE
MISSION
Rural Health: The Scenario
High burden of disease due to poverty, illiteracy and
poor outreach of health system.
Out-of-pocket expenses on healthcare of the poor is a
major cause of rural indebtedness
Emphasis on vertical programmes of health and
family welfare.
Lack of convergence with social sector programmes
related to women & child development, rural
development, panchayati raj, education, sanitation and
drinking water
Health system based on promolive and curative
system rather than preventive approach.
Ownership and accountability of HFW Programme at
community level missing.
Healthcare is one of the 7 Sutras of NCMP.
Investment in health to grow to 2-3% of GDP over next
5 years.
Focus on primary healthcare.
National Scheme for Health Insurance for poor
families.
Special care to the girl child.
Public investment in programmes to control
communicable diseases to grow.
Special attention to poorer sections for healthcare.
Focused Programme in high fertility districts.
Objectives of Rural Healthcare
Mission (RHM)
• Provide access to integrated package of health services
to poor in rural areas and urban slums
* Extend financial risk protection to poor seeking health
services
* Ensuring accountability of public health system and
cooperation with the private sector for achieving
national goals
Promote synergy between health and non-health
determinants
Strengthen Local Government Institutions to provide
leadership for Health Programmes
Strengthen
the
ongoing
process
of women
empowerment
1
Framework for RHM
•
Expanding the EAG mechanism to Rural Healthcare Mission
(RHM) for focused attention on 17 States - 8 EAG States, 8 North
Eastern States, and Jammu & Kashmir
•
5 States (U.PM M.P., Bihar, Jharkhand, Rajasthan) to be covered
under Common Minimum Programme (CMP) Strategy for focus
on population stabilization
•
8 States to be covered under North East Health Mission (NEI1M)
•
Graded packages for varying needs, based on State ownership and
articulation
*
Rural Health Mission also to be constituted at state level
•
RHM to promote integrated model of healthcare
Key Strategies under RHM
• Ensuring intra and intersectoral convergence
• Strengthening public health infrastructure
• Increased
community
ownership
and
participation
• Village level cadre of Health Workers
• Public-Private Partnership for health
• Emphasis on quality services
• Enhanced programme management inputs
Intra & Intersectoral
Convergence
Strengthening Public Health
Infrastructure
At State level, constitution of one Society for all Health
Programmes
Creation of a District Health Development Agency (DHDA) to
integrate multiple programmes of Health under one umbrella
Convergence at the State/District level of all vertical national
health programmes (including external assistance) for civil works,
drugs, equipment, training, management, IEC etc. into a District
Health Fund
Operationalising FRUs- all CHCs and 50% PHCs
Addressing mismatch of manpower and equipments at health
facilities
Strengthening the PHC with an additional doctor (AYUSH
practitioner ’)
Performance benchmarking of public health facilities
Constitution of Health Committees empowered to levy user feeGol to contribute matching share
District Health Plan to address issues of Health, Nutrition and
Sanitation
Overcome manpower deficiencies through engaging private
doctors
Options like second ANM at Sub-centres, and salary payment of
MPW (Male) by Gol, could be considered depending on
availability of Budget.
Convergence of infrastructure, including manpower, of AYUSH at
district and sub district levels. AYUSH products/medicines to be
promoted in Reproductive de Child Health (RCH) Programme.
2
Community Participation
•
Giving functional responsibilities and powers to the Panchayati
Raj bodies for planning and supervising discharge of public health
duties
•
Constitution of District, Block and Village Level Health
Committees
Raising a cadre of voluntary Accredited Social Health Activists
(ASHA) at village levels
Convergence between ANM, DOTS provider. Malaria Link
Volunteer, AWW and ASHA -Anganwadi to be the hub of health
and nutrition activities in the village
Creation of a Drug & Contraceptive depot at village level
•
•
•
•
Providing Flexible Fund at panchayat/sub*centre/district level to
enhance control over kcal issues for health and family welfare.
Community Worker
Accredited Social Health Activist (ASHA) at AWW level for HFW
activities
Honorarium of Rs. 100/- per month and performance based
remuneration, to ensure earning of about Rs. 10000/- per annum
Flexible State level model, ensuring selection by and accountability
to community organisations
5 day initial training at Sub-centre level, to be followed by periodic
on-job training
ASHA to support immunization, ANC/PNC, counseling and escort
for institutional deliveries & family planning, TB and Malaria
detection, and referrals
To act as Drug Depot for health, family welfare and AYUSH
medicine at the village level
Public-Private Partnership
for Health
Quality Control
Social Marketing/ Social Franchising of services
(sterilization, IUD insertion, institutional delivery,
immunization) and products (contraceptives) through a
network of accredited HFW Clinics
Enhanced Quality Transaction Cost (QTC) for
sterilization, IUD insertion and institutional delivery to
incentivize private participation
Arranging soft loan from banks for setting up/
upgradation of FW Clinic
Adding other RCH and curative services gradually,
through Community Insurance
• Setting up an Ombudsman at National/State level
• Constituting Quality Assurance Committees at
State/District level
• Accreditation process and branding of public/private
health facilities
• Social audit by NGOs, PRIs - triangulated verification
system
• Inclusion of the subject of Reproductive Health In
syllabi of Medical Education and emphasis on
Continuing Medical Education for both govt and
accredited private sector doctors
3
Funding for Rural Healthcare
Mission
Quality Control (Contd.)
Quality Transaction Cost in CMP States for family
planning, to provide quality service
Enforcing quality protocols for family planning
procedures
Insurance cover for acceptors and service providers of
sterilization services in Government and accredited
private clinics
Widening the basket of contraceptives under National
Family Welfare Programme
Strategy to increase contribution of NSV in sterilization
procedures
Programme and Financial
Management Inputs
Engaging skilled professionals like CAs, MBAs and
MIS specialists to strengthen State Programme
Management Unit (PMU) and District management
unit (DMU)
Creation of a National Health Resource Centre
(NHRC) to provide Technical Assistance at Gol/State
level
Introducing e-banking, GIS based MIS etc, for
improved programme management
Formalizing strategy for timely procurement and
appropriate logistic arrangement at district and sub
district levels
•
RHM to retain the EAG flexible funding mechanism
•
Proposal for funds under non-bpsable pool for North East in
MoHFW to be merged into RHM Outlay - priority of spending to
be retained for North East States
■
Funds under Departmental/Donor
State/district levels
•
Resource mapping — shared
Gol/State/Local Body Budgets
•
Funding for ASHA to be performance based under Schemes of
Health A FW
•
Initiatives under RHM need no additionality, if the 10* Plan
Outlay for Department of FW is fully funded
Scheme
funding
for
to
converge
RHM
at
through
Process Outcomes of RHM
Decentralization and convergence at villagc/district levels for
Health, Family Welfare, AYUSH & nutrition
Strengthening preventive and promotive care at community levels
Improved system of referrals
Strengthened public health infrastructure - provision of
Maintenance Fund
Accountability and responsiveness to elected Bodies of the
community
Simplification of planning aud implementation of Schemes of
Health and Family Welfare and Donor Programmes
Optimization of resources
Process Outcomes (Contd.)
•
Graded packages to cater to State specific unmet needs - health
infrastructure in NEHM and focus on population stabilization in
CMP States
•
Improved systemic capacity for programme implementation and
fund flow
•
Creation of health infrastructure in backward districts
Improving access to family welfare services and healthcare in
CMP districts through Public-Private Partnership
Quality assurance in public health programmes
•
•
•
•
•
Increased utilization of public health infrastructure
Extending financial risk protection to poor for health and family
welfare services
Community financing for maintenance of public health
infrastructure
Improvement in Health
Indicators
Burden of communicable diseases reduced
Reduction in Disability Adjusted Life Years (DALYs)
Raising level of universal immunization from 50% to
90%
Improved Infant Mortality Rate and Maternal
Mortality Ratio through increased institutional
deliveries and focus on IMNCI and immunization
Reduction in Total Fertility Rate to enable attainment
of goals of National Population Policy for 2010
Early treatment of infectious diseases
THANK YOU
5
Concept Paper
RURAL HEALTH SERVICES FOR INDIA: CURRENT NEEDS AMD FUTURE
CHALLENGE'S
1.
HEALTH CARE DELIVEiRY SYSTEM IN INDIA
The health care delivery system in the country can be broadly divided into
four sectors:
i.
Public sector including government run hospitals, dispensaries,
primary health centres, community health centres etc.
ii.
Private not-for-profit sector, including charitable institutions, NGOs,
Trusts, Missions and Churches etc.
iii.
Organised private sector for profit including private hospitals, clinics
and private practitioners.
iv.
Private informal sector including practitioners not having any formal
qualifications (faith healers, herbalists, vaidyas etc.).
2.
RURAL HEALTH INFRASTRUCTURE IN PUEJLIC SECTOR
The rural health infrastructure in public sector comprises of Community Health
Centres, Primary Health Centres and Sub- centres.
Community Health Centre
For a successful primary health care programme, effective referral support is
to be provided. For this purpose one community health centre (CHC) has beer
established for every 80,000 to 1,20,000 population, and this centre provides the
basic speciality sei-vices in general medicine, paediatrics, surgery a nd obstetrics
and gynaecology. The CHC are established by upgrading the sub-district/taluka
hospitals or some of the block level Primary Health Centres(PHC’s), or by creating
a new centre wherever absolutely needed.
Primary Health Centre
At present there is one Primary Health Centre covering about 30,000
(20,000 in hilly, desert and difficult terrains) or more population. Many rural
dispensaries have been upgraded to create these PHCs.
Each PHC has one
medical officer, two health assistants - one male and one female, and the health
workers and supporting staff. For strengthening preventive and promotive aspects
of health care, a
post of community health officer (CHO) was proposed to be
provided at each new PHC but most States did not take it up.
Sub-centre
The most peripheral health institutional facility is the sub-centre manned by
one male and one female multi-purpose health worker. At present, in most places
there is one sub-centre for about 5,000 populations (3,000 in hilly and desert areas
and in difficult terrain).
2
Village Level
Though one says that the most peripheral health institutional facility is
sub-centre, at the village level for about 1,000 population there is one health guide?
and one trained dai or traditional birth attendant (TBA),
both selected from the
community. They are trained at the PHC and the sub-centre. These two village
level functionaries are voluntary workers and not regular government employees.
They receive technical support and continuing education from ttie multi-purpose
health workers (male and female) posted at the sub-centre. Administrative support
and supervision are normally carried out by the village health committee or the
village panchayat.
3.
CURRENT SITUATION OF RURAL INFRASTRUCTURE IN PUBLIC:
SECTOR
3.1
Infrastructure
As per the Bulletin of Rural Health Statistics published by the department
of Family Welfare, MOHFW, (2003), there are 3043 Community Health Centres
(79% have government accommodation), 22842 Primary Health Centres (60%
have Govt, building) and 1,37,311 Sub centres ( 44% have Govt, building).
13.3% of positions of Medical Officers at Primary Health Centres; 48.6%
surgeons, 47.9% OBG specialists, 46.1% Physicians and 56.9% of Paediatrician
posts at Community Health Centres were vacant (2003). The vacancy position
for paramedical staff was 7.6% for ANMs, 16.1% for Multipurpose health workers
(M), 14.1% for Health Assistants (F), 13.4% for Health Assistants (M),17.4% for
Radiographers , 10.7% for Pharmacists, 14.7% for lab Technicians, and 12.5%
for nurses(2003).
3
If we compare the current position of medical and paramedical manpower
in rural areas against the recommended norm the deficit becomes much more
serious. The shortages against the recommended manpower norms was 75%
for surgeons, 75% for OBG specialists, 86% for Paediatricians. For paramedical
staff the shortage was 14.2% for ANMs, 49% for Multipurpose health workers
(Male), 14% for Health Assistants (F), 15% for Health Assistants (M), 47% fcr
radiographers, 19% for pharmacists, 49% for fab technicians and 39% for nurses.
The National Health Policy document (2002) also states that the utilisation
rates for health facilities in rural areas are low (less than 25%). The inadequate
availability of drugs, functional equipments and basic amenities affects the quality
of services through these institutions.
3.2
Financial Resources
The public health investment in the country over the years has been
comparatively low, and as a percentage of GDP has declined from 1.3 percent in
1990 to 0.9 percent in 1999. The aggregate expenditure in the Health sector is
5.2
percent of the GDP. Out of this, about 17 percent of the aggregate
expenditure
is
public health
spending,
the balance
being out-of-pocket
expenditure. The central budgetary allocation for health over this period, as a
percentage of the total Central Budget, has been stagnant at 1.3 percent, while
that in the States has declined from 7.0 percent to 5.5 percent. The current
annual per capita public health expenditure in the country is no more than Rs.
200.
3.3.
Equity
Access to, and benefits from, the public health system have been very
uneven between the better-endowed and the more vulnerable sections of
society. This is
particularly true for women,
4
children
and the socially
disadvantaged sections of society. The statistics highlight the handicap suffered
in the health sector on account of socio-economic inequity.
3.4.
National Health Programmes
Over the last decade or so. the Government has relied upon a ‘vertical’
implementational structure for the major disease control programmes. Through
this, the system has been able to make a substantial dent in reducing the burden
of specific diseases. However, such an organizational structure, which requires
independent manpower for each disease programme, is extremely expensive
and difficult to sustain. Over a long time-range, ‘vertical’ structures may only be
affordable for those diseases which offer a reasonable possibility of elimination or
eradication in a foreseeable time-span.
3.5.
Utilization of Services
As a result of such inadequate public health facilities, it has beer
estimated that less than 20 percent of the population, which seek OPD services.
and less than 45 percent of that which seek indoor treatment, avail of such
services in public hospitals. This is despite the fact that most of these patients de
not have the means to make out-of-pocket payments for private health services
except at the cost of other essential expenditure for items such as basic nutrition.
3.6.
Manpower position
While there is a general shortage of medical personnel in the country, this
shortfall is disproportionately impacted on the less-developed and rural areas. No
incentive system attempted so far, has induced private medical personnel to go
to such areas; and, even in the public health sector, the effort to deploy medical
personnel in such under-served areas, has usually been a losing battle. In such a
situation, the possibility needs to be examined of entrusting some limited public
health functions to nurses, paramedics and other personnel from the extended
health sector after imparting adequate training to them.
5
3.7.
Indigenous system of medicine
India has a vast reservoir of practitioners in the Indian Systems of
Medicine and Homoeopathy, who have undergone formal training intheirowr
disciplines. The possibility of using such practitioners in the i mplementation of
State/Central Government public health programmes, in order to increase the
reach of basic health care in the country.
Under the overarching umbrella of the national health frame work, the
alternative systems of medicine - Ayurveda, Unani, Siddha and Homoeopathy -
have a substantial role. Because of inherent advantages, such as diversity,
modest cost, low level of technological input and the growing popularity of natural
plant-based
products,
these
systems
are
attractive,
particularly
in
the
underserved, remote and tribal areas. The alternative systems will draw upon the
substantial untapped potential of India as one of the eight important global
centers for plant diversity in medicinal and aromatic plants.
3.8.
Manpower norms
It is observed that the deployment of doctors and nurses, in both public
and private institutions, is ad-hoc and significantly short of the requirement for
minimal standards of patient care.
3.9.
Quality of medical education
Apart from the uneven geographical distribution of medical institutions, the
quality of education is highly uneven and in several instances even sub-standard.
It is a common perception that the syllabus is excessively theoretical, making it
difficult for the fresh graduate to effectively meet even the primary health care
needs of the population. There is a general reluctance on the part of graduate
doctors to serve in areas distant from their native place.
It is observed that the current under-graduate medical syllabus does not
cover new emerging subjects.
6
3.10.
Need For Specialists In ‘Public Health’ And ‘Family Medicine’
In any developing country with inadequate availability of health services,
the requirement of expertise in the areas of ‘public health' and ‘family medicine’ is
markedly more than the expertise required for other clinical specialities. In India,
the situation is that public health expertise is non-existent in the private health
sector, and far short of requirement in the public health sector. Also, the current
curriculum in the graduate / post-graduate courses is outdated and unrelated to
contemporary community needs. In respect of ‘family medicine, it needs to be
noted that the more talented medical graduates generally seek specialization in
clinical disciplines, while the remaining go into general practice. While the
availability of postgraduate educational facilities is 50 percent of the total number
of qualifying graduates each year, and can be considered adequate, the
distribution
of the
disciplines
in
the
postgraduate
training
facilities
is
overwhelmingly in favour of clinical specializations. NHP-2002 examines the
possible means for ensuring .adequate availability of personnel with specialization
in the ‘public health’ and ‘family medicine’ disciplines, to discharge the public
health responsibilities in the country.
3.11.
Role of Private sector
Currently, non-Governrnental service providers are treating a large
number of patients at the primary level for major diseases. However, the
treatment regimens followed are diverse and not scientifically optimal, leading to
an increase in the incidence of drug resistance.
7
4.
SUGGESTIONS
FOR THE
FUTURE
DEVELOPMENT OF
RURAL.
HEALTH SERVICES IN INDIA
4.1.
Major Thrust Areas which need attention are:
❖ Training and development of health manpower (including available local
resources) as per the needs of the country.
❖ Integration of health with overall development to achieve effective
intersectoral co-ordination.
❖ Encouraging more active role of the community.
❖ Regionalisation of health care services with development of proper two-way
referral system.
❖ Development of integrated health care delivery system with involvement of
indigenous systems of medicine.
❖ Privatisation of health care service provision; and health care financing
(charging for services, health insurance, community funding of services).
4.2.
Proposed Strategies and Mechanisms
Main dimensions of proposed strategies and mechanisms for future actions are:
4.2.1. Training and development of health manpower
❖ Formation of an expert group for estimation of manpower needs in future.
❖ Identification of the community health needs in view of the new challenges
and up coming diseases in the communities.
❖ Development of curriculum as per these needs for the medical and
paramedical basic training programmes.
8
❖ Modification of the existing curriculum
❖ Development of new courses such as integrated course for Family
Practitioners, special short term course for medical manpower in rural areas
either after 12th class, or for the paramedical cadre after 5 years of service.
❖ Central agency to ensure quality of training. Medical Council Of India may
be expanded to effectively carry out this task or a separate agency be
fomied.
4.2.2.
Ensuring equity for the health
❖ Location of health services and facilities where these are easily accessible
and available to people especially the under-privileged sections of the
society. Facility location decisions to be taken purely based on technical and
scientific factors and not influenced by other extraneous factors.
❖ Regionalisation
of health
care
services with
clearcut geographical
demarcation for use of facilities (both in public and private sectors), along
with proper two-way referral system.
❖ Rational transfer-policies, incentives and career development opportunities
for health manpower working in remote areas.
❖ Minimising inter and intra-State differences.
4.2.3.
Strengthening health promotion and protection
❖ Development of an integrated education and health promotion programme,
with locally relevant content and media for dispersion of the messages.
❖ Development
of
Integrated
Non-Communicable
Diseases
Control
Programme.
❖ Implementation of preventive and promotive health activities in an integrated
and comprehensive manner with involvement of all health and related
sectors.
❖ Health has to be made an integral part of the development programme.
❖ Strict and effective enforcement of legislations related to health and
environment.
9
4.2.4.
Strengthening the health sector including partnership iri health
development
❖ Identification and specification of the role of public and private sector in
health.
❖ Definition and effective implementation of coordinating and monitoring
mechanisms in public and private health and related sectors.
❖ More effective involvement of the Indigenous Systems of Medicine in
provision of health care services, with specified role and responsibilities.
❖ Managerial capacity building of health managers for better management-of
health services and programmes.
❖ Consolidation of health infrastructure base by adequate resources so as to
improve the quality of services.
4.2.4.
Developing and strengthening of specific health programmes
❖ Development of an area specific comprehensive health programme to cover
all the major health problems in the given geographical area with linkages
with other related sectors, rather than having a number of vertical health
programmes, which have duplication and wastage of resources.
❖ Linking health programmes with related programmes of other sectors.
4.2.5.
Developing and using appropriate health technology
❖ Development and use of locally relevant health technologies which fit into
socio-cultural milieu( Including alternate approaches to health)
4.2.6.
Strengthening internaitional partnership in health
❖ Integrated involvement of international organisations and agencies within the
important national programmes in the health sector.
❖ A common platform for sharing experiences.
10
4.2.7.
Specific Mechanisms for Private Sector Involvement in Rural Health:
a)
Corporate Sector
The Corporate Sector should be encouraged to take responsibility for health
in a given geographical area.
i.
identification
and
listing
of corporate
houses
and
big
industries in the country, which can be assigned such task.
ii.
Specifying the health related responsibilities and tasks such as
> Opening and
maintaining tertiary level
hospitals/highly
specialised centres.
> Opening
and
maintaining
sophisticated
laboratory
or
radiological diagnostic centres.
> Management of public funded tertiary level institutions
> Sponsoring public health tertiary level institutions partly or
wholly for a given period.
> Sponsoring specific diagnostic or curative facilities in Tertiary
Public Health institutions.
> Contribution to Public health Programmes
ill.
Allocation of geographical areas for carrying out the Public
health programmes:
There are an estimated 5843 companies registered with the
National Stock Exchanges (1998). These companies can be given
the responsibility of sponsoring specific public health programmes
in nearly 5000 block in the country, depending upon their capacity
to fund such activities.
11
iv.
Incentives for corporate sector:
Incentives such as tax benefits, subsidies in raw materials, land,
water, electricity etc. can be given to these companies participating
satisfactorily in the public health programmes.
v.
For corporate hospitals subsidised land, water, electricity or
custom exemption on imported equipment etc. can be worked out.
In these hospitals about 50% of the beds be allowed for profit
earning; 20% for government functionaries on nominal rates to be
re-imburesed by the concerned organizations and rest 30% for
patients below poverty line/ poor patients free of cost.
.
b)
Non-governmental organistions (IMGOs):
Identifying the NGOs a nd a lloting them specific areas for specific
services considering the local requirements of the health system, so as to
avoid the duplication of the NGOs.
These NGOs can be given subsidized equipment, drugs, supplies
etc. along with the minimal parameters for performance out put in context
of the specified health services.
.
c)
Private practitioners:
i.
Identification parameters for private medical practitioners:
The selection of private practitioners for their involvement in
national health programmes may be done on certain criteria considering
the following:
12
> System of medicine practiced:
This may include allopathic, ISM, Ayurvedic or Homeopathic
etc.
> Number of practitioner per area/zone:
The number of practitioners to be involved for services under
national health programmes may be fixed considering the current Govt.
set up and facilities in that area.
> Minimal infrastructure with private practitioners:
Minimal infrastructure for rendering satisfactory level of services
under the national health programmes may be specified as one of the
parameters for selection of private practitioners.
> Type, mode and years in practice.
> Previous
experience
of
working
for
national
health
programmes.
> Recommendations of local professional bodies.
Role & responsibilities of private medical practitioners :
Allopathic Practitioners:
a.
General Practitioners: Case identification & referral; IEC & Health
education activities; Follow up of cases; Rendering of services; Blood
smears for passive surveillance under Malaria Control activities;
Sputum smears for suspected cases of Tuberculosis and follow up
smear examination of confirmed cases; Vaccination serviced to
children and pregnant women in the area; Distribution of condoms, oral
pills and lUCDs
b.
Paediatricians: IEC & health education activities in the clinic;
Immunisation service to children; Distribution of Vitamin A and iron folic
acid to children; ORT for diarrhoea cases
13
c.
OBG specialists: IEC & health education activities in the clinic;
Medical termination of pregnancy as per the MTP act; Immunisation
services for mothers & children; Sterilisation services ; Distribution of
condoms, oral pills and insertion of lUCDs; Diagnosis & management
of reproductive tract infections; Maternal care during ante-natal, natal &
post natal period etc.
a. Surgery specialists: IEC & Health education services in clinic &
indoor; Sterilisation & MTP services; No- scalpel vasectomy for males
e.
Ophthalmologists:IEC
&
health
education
activities;
Cataract
screening referral and operation if facilities as per the norms;
Examination of school children for eye problems under school health
programme
f.
Psychiatrists:!EC & health education activities related to HIV/AIDS ;
Counselling and management of drug users
g.
Skin specialists: IEC activities related to Leprosy, HIV/STDs/RTIs etc;
Diagnosis, referral & management of leprosy, HIV/AIDS/ STDs /RTIs
h.
Radiologists: Diagnostic support to Govt, health units if needed
i.
Pathology lab /biomedical lab/ Microbiology iab; Diagnostic support
to Govt. Health units if needed
Ayurvedic practitioner; IEC & health education activities; immunisation
of children & mothers; ORT in diarrhoea; Blood slides for passive
surveillance under malaria control activities; Distribution of Vit.A & folifer
tabs to children & mothers; Distribution of condoms s
Homeopathic practitioners: IEC & health education services;
Distribution of Vit.A & folifer tabs to children & mothers; Distribution of
condoms; Vit.A distribution; ORT in diarrhoea
Registered Medical Practitioners: (Other than above); IEC & health
education activities; Condom distribution; Vit.A distribution; ORT in
diarrhoea
14
iii.
Infrastructure for monitoring:
The existing infrastructure can be utilised for monitoring activities of the
private practitioners in national health programmes.
> Local level- Medical officers of Primary Health centres/ Community
Health Centres, Panchayat members or municipal committees etc.
> Distinct level- District health officers, District Ayurvedic officers,
local NGOs, Local Professional bodies etc.
> State level- Representatives from local professional bodies,
eminent practitioners in the state, NGOs working in health & family
welfare, etc. may be given due recognition in palling and
management of health and family welfare activities in the state.
iv.
Monitoring mechanisms:
> Minimal record of activities performed
> Simple single page periodic reporting format
> Meetings with Govt, functionaries once in month or quarter
> Field visits by Govt, functionaries once in month or quarter for
supplies and problem solving if any
> Conditions under which the contract would be terminated
> Minimal quality control of the services provided
v.
Incentives:
> Provision of Logistics & supplies:
Provision of free or subsidised drugs, equipment, vaccines, IEC
materials, maintenance of equipment etc. related to national health
programmes to the private practitioners.
> Fee for services:
Allowing the private medical practitioners to charge nominal fees for
the services rendered under the national health programmes. Poor
15
patients may be exempted from the fees and the Govt, may pay seme
honorarium for the services rendered free of cost to poor patients.
> Honorarium to practitioners:
Govt, may provide a fixed monthly amount as honorarium or
amount per unit of the services rendered for national health programmes
subject to a maximum amount per month.
> Honorary designation:
The private medical practitioners who have been involved in
providing services under national health programmes may be given
appreciation certificates & or honorary designation in lieu of the services
provided by them.
> Representation in Govt, bodies for planning and monitoring of
national health programmes:
The private medical practitioners or the representatives of their
associations like Indian Medical Association etc. may be given due
representation in bodies involved with planning and monitoring of the
national health programmes.
> Periodic training:
Suitable orientation training programmes may be planned for
orientation of private practitioners in various aspects of national health
programmes.
> Preferential treatment for cases referred by private medical
practitioners:
Due attention may be given to cases referred by the private
practitioners to designated Govt, hospitals for consultation by senior
doctors in OPD or admission, for blood bank services, biochemical and lab
investigations, pathological consultation, radiological consultation etc.
Nominal charges may be taken from the practitioners/users seeking such
services from Govt, hospitals.
16
vi.
Venue for training of private medical practitioners in national health
programmes
Venue for training of private practitioners:
The training programmes can be organised at:
> District training centres
> Health & Family Welfare Training Centres
> Medical Colleges
> Regional Training Centres
> Training through existing professional bodies like Indian Medical
Association etc.
17
9.0.
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20
0?ganis«Uor.a! Cha: i-i!
^■x-osed Reorganisation ard Linkages
Com v-\ -
Presentation before
National Advisory Council
on
Rural Health Care Mission
Department of Family Welfare
1. Community Health Volunteers
□ Department of Family Welfare proposes to
engage 3.6 lakh Accredited Social Health
Assistant (ASHA) in 10 States at village level
□ Accreditation fee @ Rs. 100 per month +
performance based remuneration for
immunisation, institutional delivery and
family planning - Rs. 10,000 / annum/ ASHA
□ Initial five day training at PHC level
□ Drug kit to be supplied containing 13 items
□ Total cost for 10th Plan Rs. 144 crores
IL Block Level Referral Hospitals
□ 50% existing PHCs i.e. 5832 PHCs and all
CHCs in 10 States under Rural Health
Mission (RHM) to be strengthened during
Phase-II of RCH programme
□ Trained manpower to be provided at these
FRUs for 24 hour emergency obstetric and
child health care services
□ Detailed Guidelines have been issued to the
States for Operationalisation of FRUs
□ Funds already released @ Rs.20 lakhs per
district for Operationalising 2 FRUs per
district in 8 EAG States
III. Accountability of Primary Health Care
Delivery System
1. XI Schedule of the Constitution includes
Family Welfare, Health and Sanitation
including Hospitals, Primary Health
Centres and Dispensaries to be entrusted to
Panchayati Raj Institutions by the State
Govts.
2. A Resolution was adopted in 8th
Conference of Central Council of Health
and Family Welfare Ministers (August
2003) that States would involve PRIs
progressively
3. Different models for involving PRIs in
Health and Family Welfare Programme are
operational at State levels
4. PRIs would need to be trained and
strengthened to handle such responsibilities
efficiently.
5. Involving PRis is an important component
of the strategy of the Department of Family
Welfare for RCH-II
IV. Great Sanitation Movement
□ The Department of Family Welfare supports
the proposal for creation of toilet facilities
under the Rural Health Mission
□ Availability of safe drinking water facilities
should also be linked with the health agenda
□ The Department of Family Welfare seeks
greater convergence with the D/o Women and
Child Development on issues related to
Nutrition, for pregnant and lactating women,
and infants
V. Health Insurance
□ The Ministry of Finance launched a
Community Based Universal Health
Insurance Scheme (CBUHIS) in 2003. The
Ministry of Health and Family Welfare was
not consulted
□ Against the aim of covering 10 million BPL,
1.16 million people covered including 11,408
BPL beneficiaries
□ Successful Health Insurance Scheme requires
modalities for both demand generation and
service provision
□ Ministry of Health and Family Welfare has
constituted an Inter-Ministerial Committee to
examine the Schemes and options for Health
Insurance Scheme
□National Commission on Macro Economics
and Health is in the process of framing
Community Health Insurance Scheme.
Report expected in three months.
VI. Accountability of Public Hospitals
□ Constitution of Hospital Committee,
empowered to levy user fees to manage funds
at institutional levels is an identified agenda
under Health Sector Reforms
□ The Agenda is being pursued with States as a
benchmark activity during RCH-11
□ The Department of Family Welfare supports
the proposal for issue of matching grant to
health institutions for user charges collected
by the Hospital Committees
VII. Campaign Mode to Combat Diseases
□ Campaign mode for Polio eradication has
yielded good results. Hope is to declare India
Polio free by 2005. Improvement in levels of
universal immunization is the next priority of
the Department of Family Welfare
□ Detailed strategy for improving immunization
includes strengthening cold chain, induction
of Auto Disposable syringes
□ Immunization sessions to be organized on
fixed days at village / habitation level at
Anganwadi centre
□ Alternate vaccine delivery strategy being
worked out
□ Free vaccines would be provided though
accredited private/ NGO Family Welfare
Clinics
Ill Reproductive Health Services
□ Department of Family Welfare has
conceptualized a Strategy for focused
population stabilisation programme in high
fertility districts as per the Common
Minimum Programme (CMP) mandate
□ All 210 districts in 5 States of UP, MP, Bihar,
Rajasthan and Jharkhand selected
□ Aims is to service unmet need for
contraception, maternal and child health in
CMP States through enhanced availability
and access to quality family welfare services,
□ The Strategy is based on voluntary approach
and addresses issues of equity, gender and
quality
□ It aims at energizing public health
infrastructure through enhanced programme
management inputs
□ Hope is to create private health infrastructure
in smaller districts
CMP Strategy (contd. I)
□ 3.6 lakhs female village health workers to be
engaged in 10 States covered under Rural
Health Mission (PHM). They would be
trained and provided Drug Kit.
□ Launching Janani Suraksha Yojana in RHM
States for promoting institutional delivery, in
both public and accredited private /NGO
Family Welfare Clinics
□ Strengthening of routine inununization
□ IMNCI package to be introduced to reduce
IMR
□ Operationalisation of First Referral Units
□ Creating a network of branded Family
Welfare Clinics for providing sterilisation,
IUD insertion, contraceptives, institutional
delivery (BPL women) and immunization
services
CMP Strategy (contd. II)
□ Arranging Bank loans on soft terms for
setting up/ upgrading FW Clinics in smaller
districts
□ Induction of skilled professionals at State and
District levels for improved programme
management
□ Revising quality transaction costs for
sterilisation services in CMP States to
improve quality of procedure
□ Setting up National and State Ombudsman to
ensure adherence to quality concerns in
Family Planning Schemes
□ Social marketing of Products (contraceptives)
and Services (sterilisation and IUD
insertions) in EAG States
CMP Strategy (Contd.III)
□ Insurance cover to acceptors and doctors
providing sterilisation services against death,
medical complications and failure of
sterilisation
□ Promotionof NSV
□ Improved programme monitoring through
Video conferencing, Web enabled MIS, and
GIS enabled MIS
□ E-Technology for social audit, and E-banking
for improved fund flow
□ Wider stakeholder partnership with related
Departments of Govenunent, NGOs,
corporate sector, professional medical
associations, PRIs
□ Focus on urban slums in 118 towns of CMP
States
□ Improved Behavioural Change
Communication focusing on Inter-Personal
Communication and availability of FW
services
'3(-<
Note Circulated by Jan Swasthya Abhiyan
at the Consultation Workshop by the National Advisory Council
on Health Care Delivery
New Delhi, 22nd September, 2004
Jan Swasthya Abhiyan : A brief Introduction
The Jan Swasthya Abhiyan (Peoples Health Movement-India) is a coalition of eighteen national
networks, including hundreds of organisations and a large number of individuals across the country,
working in the area of health care. We came together on the occasion of the People’s Health
Assembly in 2000, to create a platform that brings together diverse concerns related to Health Care.
The JSA works, through its partner organisations and state co-ordinating bodies, in almost all the
states of the country. As is underlined in the Peoples Health Charter that was adopted by the networks
constituting the JSA, we affirm “our inalienable right to comprehensive health care that includes food
security; sustainable livelihood options; access to housing, drinking water and sanitation; and
appropriate medical care for all; in sum - the right to HEALTH FOR ALL, NOW”!
We are encouraged that the National Advisory Council is focusing on vital concerns relating to
health policy. Some of the main issues we would like to bring to your consideration in the
context of the present discussion are as follows:
Incremental substantial increase in public health budget : The CMP states in unambiguous terms:
“The UPA government will raise public spending on health to at least 2-3% of GDP over the next five
years with focus on primary health care”. This commitment is indeed welcome, though it still falls
short of the WHO’s recommendation that public spending on health should be around 5% of the GDP.
However, even in order to achieve the target of 3%, yearly targets need to be formulated for the public
health budget, with assured central and expected state contributions. It would require a major increase
in budgetary support, as the present public expenditure on health care is just 0.9% of the GDP. It is
unfortunate that the 2004-05 budget, presented recently, has not recommended any significant
enhancement. If the CMP’s commitment is not to remain on paper, a plan for incremental increase in
budgetary support for Health needs to be worked out. This would mean a minimum 30-35% increase
each year, and an additional strategy to ensure enhanced budgetary support for health from state
budgets.
We note that a number of states and even the central ministry is often unable to spend the allotted
funds. This is often used as an argument within the bureaucracy to limit further budget expansion.
Such an argument is unacceptable in the context of such a widespread denial of the right to basic
health care. This failure to spend the sanctioned amount reflects poor governance and poor systems
development. A white paper should highlight the amounts of money that went unspent, at central and
state levels in the last three years, and it should assign responsibility on systems and persons for this
failure. The white paper should further state the criteria of good governance and good health systems
that would ensure that the increased budget that is so urgently required would be spent in time and
spent without gross leakages that currently characterise the system..
There is an urgent need to invest more money in health care services, food security and clean
drinking water. These issues have been neglected in budgets for far too long and though we may have
concerns that every paisa allocated to health may not be used as best as it could be in the present
circumstances due to corruption, inejficency, lack of will etc, there is no way of improving quality
without making the necessary investment.
The Village Health Worker Scheme: The CMP clearly underlines its commitment to focus on
Primary Health Care. Further the Indian National Congress in its election manifesto, states: “The
Congress will introduce a new community anchored health worker scheme and implement it with the
involvement of people's organizations and panchayati raj institutions." Similarly the Communist
Party' of India (Marxist) states in its election manifesto: "The Primary Health Care infrastructure
should include a National Community Health Worker scheme to deliver basic health services at the
habitation (village/urban settlement) level. ” Given this broad political commitment in this area we
would like to propose the following:
National Community Health Worker (CHW) scheme: A woman health worker in every village of the
country by 2009. Innovative experiments like the state level Mitanin programme in Chhattisgarh may
be taken into account while designing this scheme. Training costs and set of basic drugs for CHWs
may be Centrally funded in the initial phase, later costs of drugs and honorarium to be shared by
Union and State governments. Design of training modules (to be appropriately adapted at state level)
to be supported by the Union health ministry.
It needs to be understood that in our understanding and experience, the village health worker or
communit)’ health worker is a formal and trained worker with a formal relationship with the existing
structures of Primary Health Care Services as well as the ICDS For this scheme to be fully effective
it is essential that these basic services be made to function optimally.
Coercive population control measures: We note with dismay the CMP’s reference to '"sharply
targeted population control programmes in 150 Districts” - which we see as providing tacit clearance
to coercive measures to control population. Not only are such measures violative of basic human
rights, they have also been shown to be almost entirely useless in stabilising population. The CMP’s
position on this stands in clear variance with the National Population Policy 2000 and all related
international covenants accepted by the Indian government. There is little call to reopen a debate on
India's stated and well considered stand on population policy. Instead of arguing for incentives and
disincentives, in keeping with the spirit of the NPP 2000, steps need to be taken to eliminate all forms
of coercive population control measures and the two-child norm, which targets the most vulnerable
sections of society.
Health Insurance: The scheme suggested by the latest budget is not very different from such
schemes suggested in earlier budgets and we have seen that they have all failed. Further the schemes
run by NGOs, whether through SHGs, cooperatives etc. are not necessarily insurance schemes, they
are more in the nature of mutual funds which in some cases are using the volunrtary (or private)
insurance route. While the former set of schemes as mooted in the budgets are merely populist
proclamations, the NGO schemes are selective schemes, largely with the poor, limited to a small
population which is organised in some way by the NGO.
Insurance does not work this way. Insurance implies very large coverage and risk pooling across
classes and across the sick and healthy, young and old etc. And an insurance which is equitable also
means that it should be universal and non-discriminatory. Neiher the govts, proclamations nor the
NGO experiments fit this bill. This means you cannot have only health insurance for the poor. Health
insurance has to be for all. The question is how will the poor pay premiums. Thus the insurance
program has to be a mix of social insurance where premiums are collected from those who have
capacity to pay and state contributes the share of the poor from tax revenues. Secondly, for insurance
to function well the healthcare system, including the private sector has to be organised and regulated.
Finally, the reality that a majority of India's workforce is self-employed creates a problem of how
premiums from such working people will be collected. It is here we can learn from the NGO
experiments but review them in the context of the Bismarcan era of Germany/Prussia where mutual
fund societies of occupational groups were formed and later federated. Japan today follows a similar
system. Thus, for example, from farmers who are a very large group, a health cess via land revenues
could be collected as premium contribution and for the landless labourers they can be registered with
a state agency, like EGS etc. and the state can contribute their premium. Only such a system of health
insurance would be feasible in India but for this healthcare needs to be high up on the political agenda
and atleast 3% of GDP needs to be committed.
Health Tourism: Promotion of medical tourism locates medical care outside the community. It thus
detracts from the whole concept of primary health care. By promoting the notion that medical services
can be bought of the shelf from the lowest priced provider anywhere in the globe, it also takes away
the pressure from the State to provide comprehensive health care to all its citizens.
Medical tourism involves large, specialist hospitals run by corporate entities and constitute the tertiary
sector. It is a myth that the revenues earned by these corporates will be partly reverted to financing the
public health infrastructure. In India, there is ample evidence to show that these hospitals have not
honoured the conditionalities for receiving state subsidies - in terms of treatment of a certain
proportion of inpatients and out patients free of cost. Increased demand on private hospitals due to
medical tourism will increase the demand for health professionals in these hospitals, and thus divert
personnel from the public sector rather than strengthen them. This essentially means that majority of
the Indian population which is dependent on public provisioning will be faced with even poorer
quality of care than they are getting today. Medical tourism promotes an "internal brain drain" with
more health professionals being drawn to large urban centres, and within them, to large corporate run
specialty institutions.
The potential for earning revenues through medical tourism will become an important argument for
private hospitals demanding more subsidies from the state in the long run. In India, the corporate
private sector has already received considerable subsidies in the form of land, reduced import duties
for medical equipment etc. Medical tourism will only further legitimize their demands. This is
worrying because the scarce resources available for health will go into subsidising the tertiary
corporate sector, which constitutes only 1-2 percent of the private sector and is accessed largely by the
upper middle classes. This will also mean that the investments that are so badly needed for public
provisioning goes wanting. It then has serious consequences for equity and cost of services and raises
a very fundamental question: why should developing countries be subsidising the health care of
developed countries? Especially when this is not likely to result in any improvement of the public
health infrastructure in the country.
Campaign Mode to Combat Select Diseases: A number of National Programmes focusing on
specific diseases already exist and are languishing for want of implementational systems.
Simultaneously, campaign modes of combating diseases like malaria and polio have been and are
being experimented with. These programmes and their successes and failures need a thorough
evaluation before embarking upon this particular vertical methodology of disease reduction. In the
understanding of Jan Swasthya Abhiyan, the concept of comprehensive primary health care, as
envisioned in the Alma Ata Declaration should form the fundamental basis for formulation of all
policies related to health care The trend towards fragmentation of health delivery programmes through
conduct of a number of vertical programmes should be reversed. National health programmes need to
be integrated within the Primary Health Care system with decentralized planning, decision-making
and implementation. Focus needs to be shifted from bio-medical and individual based measures to
social, ecological and community based measures.
Such measures should include:
•
integration of health impact assessment into all development projects;
•
decentralized and effective surveillance and compulsory notification of prevalent
diseases like malaria, TB by all health care providers, including private practitioners;
•
reorientation of measures to check STDs/AIDS through universal sex education,
checking social disruption and displacement and commercialisation of sex, generating
public awareness to remove stigma and universal availability of preventive and curative
services, and special attention to empowering women and availability of gender sensitive
services in this regard.
Accountability of Primary Healthcare Delivery System and Transferring them to Local
Governments: JSA, on the whole, supports the devolution of power to Panchayats and decentralised
planning and implementation. However, health care administration is a skilled and complex task and
transferring the Primary health care system to Panchayats would be an exercise requiring much
training and planning. There are elements with Primary Health care that are amenable to quick
decentralisation such as, for example, surveillance and monitoring of Primary Health Care services
and the village health worker scheme. Systems for monitoring of Health rights, and building of
accountability of health services at village, block and district levels need to be developed. However,
‘experiment’ with decentralised health planning needs to be done in phases at a small scale to fully
understand its requirements and implications before being applied to the whole country.
Operationalising the Right to Health Care and enacting a National Public Health Act : In order
to mandate assured provision of basic health services, the Union health ministry may initiate a
discussion in the Central Council on Health (including all state health ministers) and develop a
consensus on the issue of operationalising the Right to Health Care. This may be followed by passing
a ‘National Public Health Act’ (stipulated long back by Bhore committee-1946 and Mudaliar
Committee-1961), which would specify a set of basic health services to be available to all as a right,
including legal obligations of public and private health care providers, health rights of citizens,
standards of care and certain proportion of public funds at all levels to be earmarked for public health.
State governments could pass corresponding ‘State public health services rules’ within specified time.
Regulation of the private medical sector: In keeping with the recommendations of the NHP 2002,
the government should undertake the formulation of a Draft National Act for regulation of standards,
ensuring adherence to treatment guidelines and ceiling on costs of care by private medical services.
This should be followed by enactment of state level legislation in all states in a time bound
framework.
Brief Comments on the Discussion Paper
We would also like to comment, briefly, on some specific issues raised in the Discussion Paper
circulated for the meeting convened by the NAC. We would, of course, if the NAC so desires, be
ready to comment at length - but that would require considerably more time.
Agenda for Action: Any agenda for action, if it has to be sustained, should be locally contextualized,
relevant and effective in the diversity of state health systems (since health systems are primarily state
subjects constitutionally) and must be supported by an integrated policy that locates the challenge of
health, nutrition, population, medical education, health manpower development, rational drug policy,
ISMS etc, in an integrated policy context. If these documents are discussed by different stakeholders
and finally passed by state cabinets or state legislators, then the agenda for action is protected against
changes of government, changes of personnel and moves from 'interesting whims and fancies' of a
few to serious state level commitment.
Raising an Army of Community Health Volunteers: It is unfortunate that the paper only mentions
CRHP, Jamkhed, Tribhuvandas' Foundation — rather old experience of the 1980s and early 1990s. It
would be useful to look at much larger schemes launched by the Government, and learn from their
experiences.
The Janata Government’s experiment with the VHW scheme in the late Seventies was a thorough
failure. Men were selected instead of women. The honorarium became like a salary without adequate
community preparation and social control. Thousands of health workers are still drawing this amount
because of a legal case, which the government lost.
For example, the Madhya Pradesh Government in 1994, launched a state level Jana Swasthya
Rakshak Programe with the ambitious goal of one JSR per village of MP (50,000 including the
present state of Chattisgarh). Fairly detailed review of this scheme are available - some conducted by
JSA partner organisations. The main concern of the review was to prevent such schemes from losing
focus and quality and long term perspectives and succumbing to the exigencies of populism and red
tape and bureaucratization.
These findings were discussed in the top leadership of state, but were ignored because by that time
'populism' had overtaken 'serious policy reform'. However, they made an impact on the “Mitanin”
Scheme of Chattisgarh and some policy checks have been included in the now evolving Chattisgarh
Scheme.
Many of the salient features of the proposal in the agenda of action are fraught with certain inherent
dangers, which would have long term backlash. We believe that any such scheme needs a much wider
discussion and needs to take into account a large body of experience that is available today in
launching such schemes. The scheme outlined in the paper, in our opinion, is too idealistic and does
not show adequate sensitivity to ground level realities.
Reproductive Health services and Control Measures: The Agenda for action fails to locate the
challenge of women's Health in the context of women's empowerment. Further, it is unfortunately that
it does not address issues such as Female Foeticide, Domestic Violence, Dowry Deaths?
The Discussion Paper, as it stands today, is a collation of very good innovative ideas form diverse
sources. Unfortunately, these are not linked into any cogent, coherent or experience derived process of
evolution. It, therefore, appears to be ahistorical and ad-hoc, and not adequately reflective of the
phenomenal amount of grass root experiences not only of alternative models, but alternative training,
alternative policy generation, that abounds in the country.
We believe that the best of ideas have failed in the country because they have been transplanted from
micro level innovation to state and national level experimentation without fully grasping the socio
economic - cultural - political context in which they are being scaled up. In the absence of this
understanding, the Jamkhed experiment taken up by Janata Government in 1977 was a collosal failure
and there are many such ruins - along the way. We believe the NAC has a great opportunity to prevent
this from happening by being in close touch with those who are trying experimentation and preventing
too much populism.
We appreciate the openness and the opportunity provided to dialogue. But we suggest a more
inclusive referencing paper. It was quite a surprise that none of these well known alternatives were
even noted and the paper was too full of selective primary health care strategies advocated by the
world Bank, and bio-medical techno-managerialism that need to be confronted and contextualized.
We hope these points will help to expand the discussion on health policy. Rich experience and
research is available within JSA to further elucidate this brief response to proposals that have already
been circulated within the NAC. Jan Swasthya Abhiyan would be happy to share perspectives and
frameworks for addressing issues such as a National Community Health Worker (CHW) scheme,
accountability of Primary Healthcare Delivery System and operationalising health rights, Health
insurance. Population policy, Communicable disease control, regulation of the private medical sector
and other issues with members of the NAC as and when required.
Common Minimum Programme
Priorities in Health
Shri. J.V.R.Prasada Rao,
Secretary, Health
Government of India
n
1
T
1
o
Common Minimum Program Goals
1.
INCREASE PUBLIC HEALTH SPENDING FROM
0.9% TO 2-3% GDP;
2.
CONTROL OF COMMUNICABLE DISEASES
3.
PROVIDE LEADERSHIP FOR CONTROL OF
HIV/AIDS
National Health Policy - 2002
3 Goals Related to Financing of Health:
A. Increase Public Health Spending to 2% of GDP
B. Increase Share of Central Government to 25% of State
expenditure C. Increase State Spending to from current level of 5.5% to
7% of Revenue Expenditure
Percentage of Central & State
Expenditure to GDP
C. Exp as % of GDP
S. Exp as % of GDP
Health Exp. As of GDP
2000
03(RE)
04(BE)
Share of Central to Total
Expenditure
Share of State Expenditure to
Total Revenue Expenditure
Estimated Availability of Funds in 2001
Total At 2% of GDP Rs. 1 12 000 cr.
Total At 25% of Central Share Rs. 28,000cr.
Total States Share = Rs. 84,000cr.
Current Level of Health Expenditure 20032004 = Rs. 22,505cr.
States Share - Rs. 14,535 cr.
Central Share = Rs 7,970cr.
Key Priorities for Additional Resources
Strengthening of the Primary Health System
1.
Direct Central financing of Multipurpose
Workers (M)
Amounts Required: Rs.828 er./yr.
Of the total 1.38 Sub Centers, there are no Male Workers in
almost 80,600 - largely on account of the State's poor
financial position.
Largest number of Male Workers Vacancies in the States
of Bihar, UP, Orissa etc.which have highest disease burden
Strengthening Primary Care .. Contd..
2. Honororium for Village Health Workers of Rs. 1000 per
month: 500,000 workers
Total Budget Required : Rs. 600 cr. Per year
Strengthening of the Primary Health Care System ..
Contd...
3. Provisioning of 35 Drugs Listed in the EDL to all
PHC’s
Bridging this gap will improve the utilization of the PHCs'
from current level of 19%
4.
Health Posts in Urban Areas
Strengthening of the Primary Health Care System ..
Contd...
Upscaling Community Disease Control Programs that
disproportionately affect the poor by upscaling, intensification
and sustaining the ongoing programs for the Control of
Malaria, TB and HIV/AIDS
An Estimated amount of Rs.2000 crores will b e required in
addition to the current provision of Rs. 5850 cr.
Increase Focus on Non Communicable Diseases
•
NCD - mainly Cancer, Vascular Diseases, including
Diabetes, Respiratory and chronic diseases, Mental health,
injuries and accidents etc.entailing high disease burden high contributors of impoverishment
•
NCDs' entail high burden of morbidity and mortality
•
Need to Design Programs for Emerging Diseases, namely,
diabetes, CVD, Stroke etc.
Increase Central assistance for Coping with NCD
At present GOI has 5 CSS programs for NCD
National Health Programs for:
1. Control of Blindness (Rs. 590 cr), 2. Cancer( Rs.3 80cr.)>
3. Mental Health( Rs. 215cr.), 4. Drug Addiction(Rs. 5 0.4
cr) and 5. IDD (Rs. lOcr) Total allocation of Rs.
1285.90cr.for Tenth Plan
Need to substantially increase funding to cope with
emerging diseases such as diabetes and CVD, injuries and
chronic diseases, and Trauma Care along National Highways
Expand Access to Hospital care for Underserved States
Since 1958 when AIIMS was constituted as an Institute of
Excellence no such Initiative taken to establish similar
institutes for research and medical excellence
Absence of skilled manpower and tertiary care facilities in
most states driving patients to Delhi Hospitals - overcrowding
and affecting quality and heavy economic burden on the poor
Expand Access ... contd ...
To expand access to high quality care :
Establish 6 Institutes of Excellence like AIIMS in
underserved states and provide financial support to 6 others
to upgrade existing facilities.
Outlay for next five years is Rs. 4500 cr.
Improve Quality
• Quality of Medical Education, NursingSchools a serious
concern : worsened due to the rapid and unplanned expansion
and commercialization of education
• Migration and attrition of senior faculty
• Near absence of any investment by states for upgrading the
infrastructure in medical and nursing schools
• Problems of Approvals from Medical Council of India
Improve Quality.. contd...
Three Initiatives required for improved quality in medical
education and nursing schools:
Constitute a Medical Grants Commission with a corpus
fund to provide assistance to medical schools for improving
infrastructure
Establish mechanisms for Accreditation
Provide Incentives and improved working conditions for
retention of faculty
Total Amount Required Rs. 1000 cr.
Increase Resources at State Level
States resource position likely to continue to be adverse in
the near term. 3 recommendations for improving their
resource base :
1. Earmark a percentage of total Additional Central Assistance
for Health;
2. Reduce Interest on External funding provided to States;
3.Earmark a proportion of PMGY grants for Health
4.Constitution of a Health Cess to finance State
Health Plans
Key Concerns Regarding State Health Financing
There are two key concerns that need to be addressed by
Central Government:
1. Developing a mechanism to push resources into
underdeveloped and special category states like Bihar, J&K,
Assam etc. to which external donors are not prepared to lend;
(State Health Systems Proj ects)
2. Establish monitoring systems in the Planning
Commission to ensure progressive increases in the
Health Budgets of the states while approving their
Annual Plans
Summing Up - Central
Additional Expenditures : Rs/crores by 2010
Intensification of ongoing Communciable disease
programs Rs. 2000cr.
New Initiatives :
1. New programs for NCD's: Rs. 1285 cr.
2.
Medical Grants Commission ^Rs. lOOOcr.
3.
Central Financing of MPW (M)&VHW Rs. 1428cr. per
year
4.
Drugs for PHC's = Rs. 500cr. per year
5.
Institutions of Excellence = Rs. 4800cr.
6. Urban Health Posts = Rs. lOOOcr. for 5 years.
Summing Up - States
I
2.
3.
4.
5.
6.
Increased Resource Transfers
ACA
PMGY
Reduction of interest on loans
Health Cess
Increased Commitment of State resources to Health
through the Plan process
External funding through Health Systems Projects for
infrastructure Development.
Mission for Rural Health Care Delivery in Selected States
(Draft Document for Discussion)
Preamble:
This Mission seeks to improve rural health care delivery in states where it is weakest at
present by ensuring a provider in each village, effective hospital care to rural population
and cqyerged action on health and the determinants of health for maximum impact. The
Mission will be the instrument to integrate multiple vertical programmes at the District
level along with their funds. The Mission will ensure right to every child^ in these states
in India to basic health services.
Current Situation:
> Health Status of the people ip the extremely poor in rural areas of the 10 states of
Bihar, Jharkhand, Madhya Pradesh, Chattisgarh, Orissa, Rajsathan, Uttar Pradesh,
Uttaranchal, Assam, Jammu and Kashmir and the states ofNorth East
> Poverty and ill-health are mutually reinforcing
> Status of public provisioning of health care weak where it is needed most
> These states also contain the 150 population-focus districts: New national
response required
> Health Sector has not utilised opportunity for inter-sectoral action provided by
Panchayat Raj
> Health output dependent on action for health combined with action on key
determinants of health like safe water, sanitation, nutrition etc., Panchayat Raj has
mandate also over these determinants
> Opportunity to redesign ineffective national programmes mandate in NCMP/PJH’s
directive to revamp delivery
Rural Health through a Citizen Lens
•
•
•
•
•
•
“Burden of disease high on account of poverty and illiteracy”
“There is no official health provider in the village” (in most villages in these
states)
“There is a designated ANM (MPW). Located elsewhere so visits, at best, twice a
month”
“Most deliveries take place at home - Nearest PHC (20Kms) anyway cant provide
institutional care”
“The nearest effective unit for hospital care is the CHC, about 40 Kms away
“There are private providers close by whose services are paid for”
Rural Health through Government Lens
•
There is a Multi-purpose Worker (Male and Female) for population of 3000-5000
at the Sub Centre as First Unit
•
•
The next Unit is the one for Hospital Care - Sector PHC for a population of
30,000 - 1,00,000 (About 40 villages) with one doctor, one nursing assistant, one
ward boy, dresser, 2 sector supervisors and 2 MPW. It also has 6 beds
There is a Community Health Centre for a population of over 1 Lakh. With over
10 doctors, nursing staff, lab technicians, radiologists etc., and about 40 plus beds.
High Occupancy rate
Rural Health and Government Provisioning: Why does it fail?
•
•
•
•
•
•
•
•
•
First Unit of MPW (ANM) fails because not a resident of the village
Second Unit of PHC a planning failure of serious proportions. Utilisation of beds
0 to 2%. A mixed-up model combining inpatient care and outreach function not
doing either
Means citizen gets effective referral care only at CHC-about 40 kms away
Though private providers exist, there is no link with them for Public health
MPW (ANM) is an extension of the government into the village - not a “finger of
the community going up” therefore comes with government’s health agenda and
not structured to respond to people’s health needs
Government does not simultaneously act on the causes of ill-health (preventive
action on determinants)
Private providers are not accredited and therefore do an entrepreneurial function,
not a public health one
Government has “programmes for individual diseases” and not a plan for
comprehensive health care
Health Care delivery is completely top-down with priorities set in Delhi and
flowing down
Some serious planning errors/need for correction
•
•
•
•
•
•
.
.
•
•
ANM (MPW) conceived on population - norm and needs to be based on
habitation-norm
Sub Centre has no autonomy
Sector PHC cannot do impatient care and so needs to be reconfigured as outreach
unit only
CHC can be strengthened to become first effective referral unit only
District has no space to plan for itself - therefore cant link effectively with
determinants
No collective platform for health at district-level which includes private
providers, other non allopathic providers
State level budgets being spent mostly on salaries and medicines, GOI has
become the real player in programme design - more so for poorer states
Resource constraints and importance of health goals have brought in large number
of donors: in absence of an integrating framework donor-catalysed programmes
further fragment comprehensive health care into “selective” goals
Within States, areas are carved out for different donor agencies
Each programme operates as a vertical silo
2
•
•
•
Too many vertical programmes with no horizontal connections
Every programme exhorts “intersectorality” but in practice fragment resources
and dissipate energies
In short health sector which needs “extra-sector action” to be effective, is
internally fragmented
What could be done?
•
•
•
•
Step 1: Simple horizontal integration at the district level of all vertical
programmes under the format of Rural Health Care Delivery Mission
A “funnel” approach to doing this: May be many on top but flow into one
common pool at district level
GOI will create on Omnibus Centrally Sponsored Programmed called “District
Rural Health Care Delivery Mission” and put under it the following programmes
Programmes for integration of funds at district level under the common head
of the Mission:
a)
Strengthening of Rural Health Infrastructure
b) Population control
c) Reproductive and Child Health
d) National Malaria Programme
e)
National Leprosy Eradication Programme
0
National Kala Azar Programme
g) National Programmed for Control of Blindness
h) National Iodine Deficiency Disorders programme
i)
National Filaria Programme
j)
Revised National Tuberculosis Programme
National AIDS Programme and National Cancer Programme may be
separately considered
•
•
•
•
These different programmes will be budgeted under the common head and
resources passed on to districts through states
Monitoring would be done by the centre and states for which separate streams for
monitoring will be retained at Centre/State levels
This will mean dissolving the multiple societies that now exist for managing these
programmes into one common Health Society at the District level. Could be
chaired by the Chairperson ZP, with collector as Co-Chair and CMHO as
secretary. Operation of cheque by any two
All of the above to be done by GOI
Step 2: District Health Plan as Programme Instrument and following
components
a) Provider in Each Village: Government provider mapping and filling up gaps
by training one person in each village as a barefoot doctor (in those villages
where none exist)
3
•
b)
Government to provide training, kit, link with the sub Health
Centre/PHC. She/He entitled to practice as government certified
community health activist
Facility’: Government will try and provide a health room in each village (if
resources permit: this is not considered essential, especially in low -density
population villages)
•
c)
Every untrained dai will be trained in each village (many have
already been trained)
Organisation
A Frontline team for health in each village with elected Panchayat,
ANM/Community health Activist, Dai/teacher/anganwadi worker
d)
Support from Private providers
District to identify and register all private providers and link them effectively
with public health provisioning
e)
Strengthening Facilities at Sub Centre, PHC, CHC
> Untied fund of Rs. 5000 per year as Community Health Action Fund to
ANM/MPW to catalyse frontline team for action on health and
determinants
> Sector PHC given territorial responsibility and its medical staff deployed
with CHC, if state so wishes
> CHC strengthened with community monitoring through Patients Welfare
Committee
> CHC allowed to levy user charges, more for accountability (poor can be
exempted to avoid any such criticism that poor are being charged)
f)
District Health Plan
•
•
•
g)
This plan should detail action under components (a) to (e) and suggest
collaborative action for determinants through sectors like safe water,
sanitation, nutrition etc.,
It could contain ideally an (g) untied fund for supporting local action
The District Health Society will have on it intersectoral functionaries who
can operationalise such a plan
What could be done: Supportive Action
4
•
•
•
•
District Health Society will pool existing personnel under different
societies for managerial support: Gaps here will be provided for (example,
accounts staff)
Private Sector, NGO Collaboration would be enabled at district level
through district health plans
District Public Health report will be presented each year on status under
key components
Concurrent review will be done by non government organisations
Mission Output
•
•
•
•
•
•
•
•
•
•
•
•
•
•
At the village level, every village gets a provider - either MPW or
Community Health Activist
At the Village level, if possible, a health room
At the Village level, a trained dai in each village
At the Village level, a sensitised frontline team of panchayat, MPW,
Anganwadi, etc.,
At the Village level, action on determinants of health
At Village (cluster) level, a better functioning sub health centre with
untied funds for community health action
A better functioning CHC for hospital care
Each CHC working under community control, with local resource
mobilisation
At district level, a coordinated plan that links with private providers
At district level, a coordinated plan with action on determinants
At District level, integration of resources internal to health sector and
combining with outside sector funds
At district level, effective support staff
At District level, effective programme review and public accountability
Impact on IMR, MMR, Universal Immunisation, Reduction in
Communicable diseases in 4 years, mainstreaming AIDS prevention,
leading to population stabilisation.
Everybody Wins
•
•
•
•
•
•
Citizens get improved health services
Local bodies / District gets leadership roles in planning for their area
State Governments/State managers get freedom from Vertical programmes
that dissipate energies
Government of India is able to target its resources better and ensure better
outcomes
Private Sector, NGOs get space to collaborate
Development partners get value for money
5
Mission Implementation:
Structure (For all Missions)
•
•
•
•
•
•
Mission Coordinating Group headed by the Prime Minister with Deputy
Chairman Planning Commission, Ministers of Mission areas, Cabinet
Secretary and Principal Secretary to PM
National Mission for Rural Flealth Care Delivery located in the Ministry of
Health ( Family Welfare)
Mission Steering Group headed by the Minister of Health, Secretaries of the
three wings of Health, Member Planning Commission, Secretaries of WCD,
Elementary education and Literacy, Experts. Mission located in Department
of Family welfare with a Mission Director ( at JS level)
State level Missions headed by the Chief Minister with similar composition
State level Steering Group headed by the Chief Secretary
District level Mission with ZP as chairperson, Collector as Co-chairperson
and CMHO as Secretary and heads of Committees for health, education,
WCD in ZP etc., as members along with district heads of Departments,
representatives of private providers, NGOs, Experts on public health etc.,
Next Steps:
•
•
•
•
•
Circulation of the draft Mission outline to a selected group of experts and
representatives of states taken up under the Mission: 15-18 September
Meeting to finalise Mission and setting deadlines for state-level documents: 1st
week of October
Finalisation of the National Mission Document: 15 October
Cabinet Clearances etc.: 15-30 October
Mission to commence : 14 November
6
Page 1 of 4
________
PHM-Secretariat
From:
To:
Sent:
Subject:
"sushama rath" <sushamarath@yahoo.co.in>
<secretariat@phmovernent.org>
Tuesday, October 05, 2004 3:12 PM
Rural Health Mission
Dear Sir.
As already informed in the invitation letter TA/DA will paid to you including air travel by economy class.
Overview of Rural Health Care Mission is hereby sent.
Sushama Rath
Under Secretary' (ID/EAG)
OVERVIEW OF RURAL HEALTHCARE MISSION
STRATEGIC INPUTS
INSTITUTIONAL.• Expanding the EAG mechanism to Rural Healthcare Mission (REIM) for focused attention on 17
States- 8 EAG States (U.P., M.P., Bihar, Rajasthan, Orissa, Jharkhand, Uttaranchal and
Chhattisgarh), 7 North Eastern States (Assam, Arunachal Pradesh, Manipur, Meghalaya,
Mizoram, Nagaland and Tripura), Jammu & Kashmir and Sikkim
• 5 States to be covered under Common Minimum Programme (CMP) Strategy for focus on
population stabilization
. 8 States to be covered under North East Health Mission (NEHM)
. Graded packages for varying needs, based on State ownership and articulation
• At national level, RHM to be presided over by PM/HFM
. At state level, RHM to be presided over by CM/State Health Minster
• RHM to include agendas of the 3 Departments of Health, FW and A YUSH ------ Ulcrv-e.
INTRA & INTERSECTORAL CONVERGENCE:
• All vertical national health programmes and donor funds to converge at the State/District level
. Funds for civil works, drugs equipment, training management and IEC pooled together into a
District Health Fund for which a composite District Health Plan shall be made
. Creation of a District Health Development Agency (DHDA)
10/5/04
Mission for Rural Health Care
Delivery in Selected States
Draft Document for Discussion
Preamble
This Mission seeks to improve rural health care
delivery in states where it is weakest at present by
ensuring a provider in each village, effective
hospital care to the rural population and converged
action on health and the determinants of health for
maximum impact. The Mission will be the
instrument to integrate multiple vertical
programmes at the District level along with their
funds. The Mission will ensure the right of every
child in these states in India to basic health
services
2
Current Situation
• Health status of the people is extremely poor in
the rural areas of the 10 states of Bihar, Jharkhand,
Madhya Pradesh, Chattisgarh, Orissa, Rajasthan,
Uttar Pradesh, Uttaranchal, Assam, Jammu and
Kashmir and states in the North-East
• Poverty and ill-health are mutually reinforcing
• Status of public provisioning of health care weak
where it is needed most
• These states also contain the 150 population-focus
districts: New national response required
Current Situation
• Health Sector has not utilised opportunity for
intersectoral action provided by panchayat raj
• Health output dependent on action for health
combined with action on key determinants of
health like safe water, sanitation, nutrition etc.
Panchayat Raj has mandate also over these
determinants
• Opportunity to redesign ineffective national
programmes mandate inNCMP/PM’s directive to
revamp' delivery
4
Rural Health through a Citzen
Lens
44 Burden of disease high on account of poverty and
illiteracy”
44 There is no official health provider in the village”(in
most villages in these states )
44 There is a designated ANM( MPW). Located
elsewhere so visits, at best, twice a month”
“Most deliveries take place at home—the nearest PHC
(20 kms) anyway cant provide institutional care”
“The nearest effective unit for hospital care is the CHC,
about 40 kilometers away”
44 There are private providers close by whose services
are paid for”
5
Rural Health Care through
Government Lens
• There is a Multi-Purpose Worker ( Male and Female)
for population of 3000-5000 at the Sub Centre as First
Unit
e The next unit is one for hospital care- Sector PHC for a
population of 30,000-1,00,000 ( about 40 villages) with
one doctor, one nursing assistant, one ward boy,
dresser, 2 sector supervisors and 2 MPW. It also has 6
beds
• There is a Community Health Centre for a population
of over 1 lakh. With over 10 doctors, nursing staff, lab
technicians, radiologists etc and about 40 plus beds.
High occupancy rate
6
Rural Health and Government
Provisioning: Why does it fail?
• First Unit of MPW ( ANM) fails because not a
resident of the village
• Second unit of PHC a planning failure of serious
proportions. Utilisation of beds 0 to 2%. A
mixed-up model combining inpatient care and
outreach function not doing either
• Means citizen gets effective referral care only at
CHC- about 40 Kms away
• Though private providers exist, there is no link
with them for public health
7
Rural Health and Government
Provisioning: Why does it fail?
• MPW ( ANM) is an extension of the government into
the village—not a “finger of the community going up” therefore comes with government’s health agenda and
not structured to respond to people’s health needs
o Government does not simultaneously act on the causes
of ill-health ( preventive action on determinants)
• Private providers are not accredited and therefore do
an entrepreneurial function, not a public health one
• Government has “ programmes for individual
diseases” and not a plan for comprehensive health care
• Health care delivery is completely top-down with
priorities set in Delhi and flowing down
8
Some serious planning errors/
need for correction
• ANM( MPW) conceived on population- norm and
needs to be based on habitation-norm
• Sub Centre has no autonomy
• Sector PHC cannot do inpatient care and so needs
to be reconfigured as outreach unit only
• CHC can be strengthened to become first effective
referral unit
• District has no space to plan for itself—therefore
cant link effectively with determinants
9
Some serious planning errors/
need for correction
• No collective platform for health at district-level
which includes private providers, other non
allopathic providers
* State level budgets being spent mostly on salaries
and medicines, GOI has become the real player in
programme design—more so for poorer states
• Resource constraints and importance of health
goals have brought in large number of donors: in
the absence of an integrating framework donorcatalysed programmes further fragment
comprehensive health care into” selective” goals 10
Some serious planning errors/
need for correction
• Within states, areas are carved out for different
donor agencies
• Each programme operates as a vertical silo
* Too many vertical programmes with no horizontal
connections
• Every programmes exhorts “intersectorality” but
in practice fragment resources and dissipate
energies
• In short health sector which needs “extra-sector
action” to be effective, is internally fragmented
n
What could be done?
• Step 1: Simple horizontal integration at the district
level of all vertical programmes under the format
of Rural Health Care Delivery Mission
• A “ funnel” approach to doing this: May be many
on top but flow into one common pool at district
level
• GOI will create one omnibus Centrally Sponsored
Programme called “ District Rural Health Care
Delivery Mission” and put under it the following
programmes
What could be done?
Programmes for integration of funds at district level
under the common head of the Mission:
(a) Strengthening of Rural Health Infrastructure (b)
Population Control © Reproductive and Child Health
(d) National Malaria Programme (e) National
Leprosy Eradication Programme (f) National Kala
Azar Programme (g) National Programme for
Control of Blindness (h) National Iodine Deficiency
Disorders programme (I) National Filaria
Programme (j) Revised National Tuberculosis
Programme
(b) National Aids Programme and National Cancer
Programme may be separately considered
j
•
What could be done?
• These different programmes will be budgeted under
the common head and resources passed on to districts
through states
• Monitoring would be done by the Centre and States for
which separate streams for monitoring will be retained
at Centre,zState levels
• This will mean dissolving the multiple socities that now
exist for managing these programmes into one common
Health Society at the District level. Could be chaired
by the Chairperson ZP, with Collector as co-Chair and
CMHO as Secretary. Operation of cheque by any two
• All of the above to be done by GOI
14
What could be done?
Step 2: District Health Plan as Programme Instrument and
following components
(a) Provider in Each Village: Government Provider mapping and
filling up gaps by training one person in each village as a barefoot
doctor( in those villages wher$ none exist)
• Government to provide training, kit, link with sub Health
Centre/PHC. She/He entitled to practice as government certified
community health activist
(b) Facility: Government will try and provide a health room in each
village (if resources permit: this is not considered essential,
especially in low-density population villages)
15
What Could be done?
e Every untrained dai will be trained in each village
( many have already been trained)
© Organisation
A frontline team for health in each village with
elected panch,ANM/Community health
activist. dai/teacher/anganwadi worker
(d) Support from private providers
District to identify and register all private
providers and link them effectively with public
health provisioning
16
What could be done?
(e) Strengthening Facilities at Sub Centre, PHC, CH.C
Untied fund of Rs 5000 per year as Community Health
Action Fund to ANM/MPW to catalyse frontline tean
for action on health and determinants
Sector PHC given territorial responsibility and its
medical staff deployed with CHC, if state so wishes
CHC strengthened with community monitoring
through a Patients Welfare Committee
CHC allowed to levy user charges, more for
accountability (poor can be exempted to avoid any
cz5
such criticism that poor are being charged)
17
What could be done?
(f) District Health Plan
° This plan should detail action under components
(a) to (e) and suggest collaborative action for
determinants through other sectors like safe water,
sanitation, nutrition etc.
9 It could contain ideally an (g) untied fund for
supporting local action
e The District Health Society will have on it
intersectoral functionaries who can operationalise
such a plan
18
What could be done: Supportive
Action
s District Health Society will pool existing personnel
under different societies for managerial support: Gaps
here will be provided for( example, accounts staff)
* Private sector, NGO collaboration would be enabled at
district level through district health plans
6 District Public Health Report will be presented each
year on status under key components
6 Concurrent review will be done by non government
organisations
19
Mission Output
9 At the village level, every village gets a providereither MPW or Community Health Activist
• At the village level, if possible, a health room
0 At the village level, a trained dai in each-village
° At the village level, a sensitised frontline team of
panch,MPW,Anganwadi worker etc
• At village level, action on determinants of health
• At village ( cluster) level, a better functioning sub
Health Centre with untied funds for community
health action
20
Mission Output
•
°
°
°
0
»
•
•
A better functioning CHC for hospital care
Each CHC working under community control, with local resource
mobilisation
At District level, a coordinated plan that links with private
providers
At District level, a coordinated plan with action on determinants
At District level, integration of resources internal to health sector
and combining with outside sector funds
At District level, effective support staff
At District level, effective programme review and public
accountability
Impact on IMR, MMR, Universal Immunisation, Reduction in
Communicable Diseases in 4 years, mainstreaming Aids
prevention, leading to population stabilisation
21
Everybody wins
9 Citizens get improved health services
* Local bodies/ District gets leadership roles in
planning for their area
0 State governments/ state managers get freedom
from vertical programmes that dissipate energies
9 Government of India is able to target its resources
better and ensure better outcomes
e Private Sector, NGOs get space to collaborate
• Development Partners get value for money
22
Mission Implementation:
Structure ( for all Missions)
• Mission Coordinating Group headed by the Prime
Minister with Deputy Chairman Planning Commission,
Ministers of Mission areas, Cabinet Secretary and
Principal Secretary to PM.
• National Mission for Rural Health Care Delivery
located in the Ministry of Health ( Family Welfare).
•. Mission Steering Group headed by Minister of Health,
Secretaries of the three wings of health, Member
Planning Commission, Secretaries of WCD,
Elementary Education and Literacy,Experts. Mission
located in Department of Family Welfare with a
Mission Director ( at JS level)
23
Mission Implementation
8 State level Missions headed by the Chief Minister
with similar composition
8 State level Steering Group headed by the Chief
Secretary
• District level Mission with ZP as Chairperson,
Collector as Co-Chairperson and CMHO as
Secretary and heads of Committes for health,
education, WCD in ZP etc as members along with
district heads of Departments, representatives of
private providers, NGOs, experts on public health
etc.
24
Next Steps
° Circulation of the draft Mission outline to a
selected group of experts and representatives of
states taken up under the Mission: 15-18
September
G Meeting to finalise Mission and setting deadlines
for state-level documents: 1st week of October
• Finalisation of National Mission Document: 15
October
• Cabinet Clearances etc 15-30 October
® Mission to commence: 14 November
25
National Rural Health Mission
A Promise of
Better Healthcare Service for the Poor
A summary of
Community Entitlements
and
Mechanisms for Community Participation and Ownership
for
Community Leaders
Prepared for
Community Monitoring of NRHM - First Phase
National Rural Health Mission
A Promise of
Better Healthcare Service for the Poor
A summary of
Community Entitlements
and
Mechanisms for Community Participation and Ownership
for
Community Leaders
Prepared for
Community Monitoring of NRHM - First Phase
A Promise of Better Healthcare Services For The Poor
Briefing Note Compiled by: Abhijit Das, Gitanjali Priti Bhatia
Illustrations by: Ganesh
Printed at: Impulsive Creations - 9810069086
A Promise of Better Healthcare Services For The Poor
Contents
Preface
04
An Introduction- NRHM
05
Service Guarantees Important Schemes and
Provisions under NRHM
■
ASHA
■
ANM
■
JSY
■
Service guarantees from Sub Health Center
■
Service guarantees from Primary Health Center
■
Service guarantees from Community Health Center
□
AYUSH
06
Community Participation in NRHM
■
Village Health and Sanitation Committee
■
PHC Monitoring and Planning Committee
■
Block Monitoring and Planning Committee
■
District Health Monitoring and Planning Committee
■
State Health Monitoring and Planning Committee
■
Rogi Kalyan Samiti
14
Some Frameworks for Community Monitoring
El
Indian Public Health Standards
■
Charter of Citizen’s Health right
■
Concrete Service Guarantees
20
Annexure
23
Model Citizens Charter for CHCs and PHCs
A Promise of Better Healthcare Services For The Poor
Preface
he National Rural Health Mission has been launched with the
objective of improving the access to quality healthcare services for
the rural poor, especially women and children. The Mission
recognizes that good health is an important component of overall socio
economic development and an improved quality of life.
T
Tire most significant aspect of NRHM is that it is not a new health
scheme or programme but a new approach to providing healthcare
services. Some of the important components of this approach is that it
>
recognizes the importance of integrating the determinants of health,
like nutrition, water and sanitation with healthcare systems
>
aims at decentralizing planning and management
>
integrates organizational structures-i.e. the different vertical health
schemes
>
improves delivery of healthcare sendees through upgrading and
standardizing health centres
>
introduces standards and guarantees for service quality and
triangulated monitoring systems for assuring quality
>
provides mechanisms for community participation and management
This short briefing note has been prepared by pooling together all the
manuals and guidelines that have been prepared to guide the
implementation of NRHM and highlights its key components which
relate to Entitlements, Mechanisms for Community Participation and
Yardsticks for Community Monitoring. It is expected that this
information will prove useful for all those involved in the Community
Monitoring processes at the district, block and village levels.
This briefing note has been prepared as a part of the Community
Monitoring of NRHM (first phase) being implemented by the Advisory
Group on Community Action.
A Promise of Better Healthcare Services For The Poor
Some of the Core Strategies through which
the mission seeks to achieve its goals:
An Introduction to
NRHM
he Government of India launched the National
Rural Health Mission (NRHM) on the 12th of
April 2005.The vision of the mission is to
undertake architectural correction of the health system
and to improve access to rural people, especially poor
women and children to equitable, affordable,
accountable and effective primary health care
throughout the country with special focus on 18 states,
which have weak public health indicators and/or weak
infrastructure.
T
18 special focus states are Arunachal Pradesh, Assam,
Bihar, Chattisgarh, Himachal Pradesh, Jharkhand,
Jammu and Kashmir, Manipur, Mizoram, Meghalaya,
Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim,
Tripura, Uttaranchal and Uttar Pradesh.
Some of the goals of the Mission:
Reduction in child and maternal mortality
>
Universal access to public health care services
along with public services for food and nutrition,
sanitation and hygiene
>
Prevention and control of communicable and noncommunicable diseases, including locally endemic
diseases
>
Access to integrated comprehensive primary health care
Train and enhance capacity of Panchayati Raj
Institutions (PRIs) to own, control and manage
public health services
>
Promote access to improved
household level through (ASHA)
>
Health Plan for each village through Village
Health Committee
>
Strengthening existing
CHCs
>
Preparation and Implementation of an inter
sectoral District Health Plan
>
Integrating vertical Health and Family Welfare
programmes at National, State, Block, and District
levels
healthcare
at
sub-centre, PHCs and
Unlike previous health programmes, the government
has clearly defined the roles of Non governmental
organization (NGOs) in the Mission. NGO’s are not
only included in institutional arrangement at National,
State and District Levels but also they are supposed to
play an important role in monitoring, evaluation and
social audit.
NRHM is a 7 years programme ending in the year
2012. It has time bound goals and its progress will be
reported publicly by the government.
>
>
Source of Information: Mission document http://
mohfw.nic.in/NRHM/Documents/NRHM%20Mission%
20Document.pdf
For more Information on NRHM vision, goals,
objectives, strategies and outcomes go to:
1) Framework for Implementation. http://mohfw.
nic.in/NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
2) Website on NRHM by Ministry' of Health and Family
Welfare http://mohfw.nic.in/NRHM/NRHM.htm
5
A Promise of Better Healthcare Services For The Poor
Roles and Responsibilities
ASHA is responsible for creating Awareness on Health
including
Service Guarantees and
Important Schemes and
Provisions under NRHM
>
Providing information to the community on
nutrition, hygiene and sanitation
>
Providing information on existing health services
and mobilizing and helping the community in
accessing health related services available at
Health Centers
>
Registering pregnant women and helping poor
women to get BPL certification
>
Counseling women on birth preparedness, safe
delivery, breast feeding, contraception RTI/STI and
care of young child
Since Sub centers were serving much larger population
than they were expected to and ANMs were heavily
overworked, one of the core strategies of NRHM is to
promote access to improved healthcare at household
level through ASHA.
>
Arranging escort/accompany pregnant women and
children requiring treatment/admission to the
nearest health centre.
>
Promoting universal immunization
>
ASHA is a Health Activist in the community
>
>
Every village will have 1 ASHA for every 1000
persons
Providing primary medical care for minor ailments.
Keeping a drug kit containing generic AYUSH and
allopathic formulations for common ailments
>
Promoting construction of household toilets
>
She will be selected in a meeting of the Gram Sabha
>
>
She will be chosen from women (married/widowed/
divorced between 25-45 years) residing in the
village with minimum education up to VHIth class.
Facilitating preparation and implementation of the
Village Health Plan through AWW, ANM,SHG
members under the leadership of village health
committee
>
ASHA is accountable to the Panchayat
>
Organizing Health Day once/twice a month at the
anganwadi with the AWW and ANM
>
ASHA will work from the Anganwadi Centre
>
>
ASHA is honorary volunteer and she is entitled to
receive performance based compensation. Her
services to the community are Free of cost
ASHA is also a Depot holder for essential services
like IFA, OCP, Condoms, ORS DDK etc, issued by
AWW
>
ASHA will receive trainings on care during
pregnancy, delivery, post partum period, New bom
care, sanitation and hygiene
Accredited Social Health Activist
(ASHA)
ith the launch of NRHM, the Government of
India proposed Accredited Social Health
Activist (ASHA) to act as the interface
between the community and the public health system.
W
Timeline: Fully trained ASHA for every 1000
population/large-isolated habitations in 18 Special
Focus States-30% by year 2007, 60% by 2009 and 100%
by 2010
6
A Promise of Better Healthcare Services For The Poor
Source of Information:
(1) Guidelines on ASHA- It has been envisaged that
states will have flexibility to adapt these guidelines
keeping their local situations in view.
http://mohfw.nic.in/Guidelines%20on%20ASHAAnnex%201. pdf
>
Maintenance of all relevant records concerning
mother, child and eligible couples in the area
>
Providing information on different family planning
and Contraception methods and Provision of
Contraceptives
(2) Framework for Implementation (*) http://mohftv.nic.
in/NRHMZDocuments/NRHM%20-%20 Framework
%20for%20Implementation.pdf
>
Counseling and correct information on safe
abortion services
>
Coordinates services with AWWs, ASHA, Village
Health & Sanitation Committee and PRI for
observance of Health Day at AWW center at least
once a month
>
Coordination and supervision of ASHA
>
The Untied grant to the Sub Center is kept in a
joint account, which is operated, by the ANM and
the local Sarpanch
For more Information on ASHA go to:
1) Guidelines on JSY http://mohfw.nic.in/doftv%20website/
J SY_features_FAQ_N ov_2006.htm
2) Website of Ministry of Health and Family Welfare
http://mohftv.nic.in/NRHM
Auxiliary Nurse Midwife (ANM)
ANM is answerable to Village Health and Sanitation
committee, which will oversee her work.
ANM is a government paid health worker who provides
free maternal and childcare services within a sub
center area. The Mission seeks to provide minimum
two ANMs at each Sub Health Centre to be fully
supported by the Government of India.
Source of Information:
Framework for Implementation http://mohftv.nic.in/
NRHM/Documents/ NRHM%20-%20Framework%20for
%20 Implementation.pdf
Primary tasks of ANM
>
Registration of all pregnancies (ANM along with
ASHA will ensure that all BPL women get benefits
under Janani Suraksha Yojna)
For more Information on JSY go to:
1) Guidelines on JSY http://mohfw.nic.in/dofw%20
website/JSY_features_FAQ_Nov_2006.htm
>
Ensure Minimum 4 antenatal check ups along
with 100 IFA tablets and two T.T. Injections to
pregnant women
2) Website of Ministry of Health and Family Welfare http://mohfw.nic.in/NRHM
>
Appropriate and prompt referral in case of highrisk pregnancies
JANANI SURAKSHA YOJANA
(JSY)
>
Provide Skilled Attendance at home deliveries,
post partum care and contraceptive advice
JSY is meant to reduce maternal mortality and neo-natal
mortality by promoting deliveries at health institutions
by skilled personnel like doctors and nurses.
>
Newborn Care (full immunization and Vitamin A
doses to children, prevention and control of
childhood diseases like malnutrition, infections etc.
>
JSY is a 100% centrally sponsored scheme. It
integrates cash assistance to women from poor families
for enabling them to deliver in health institutions along
with anti natal and post natal care.
Curative Services like treatment for minor ailments
7
A Promise of Better Healthcare Services For The Poor
The scheme applies differently to LPS and HPS.While
states having low institutional delivery rates have been
named as Low Performing States (LPS), the remaining
states have been named as High Performing States
(HPS). LPS states include the states of Uttar Pradesh,
Uttaranchal, Bihar, Jharkhand, Madhya Pradesh,
Chhattisgarh, Assam, Rajasthan, Orissa and HPS states
include Maharashtra and Tamilnadu.
Assistance for Home Delivery
In LPS and HPS States, BPL pregnant women, aged 19
years and above, preferring to deliver at home is
entitled to cash assistance of Rs. 500/- per delivery.
Such cash assistance would be available only upto 2
live births and the disbursement would be done at the
time of delivery or around 7 days before the delivery by
ANM/ASHA/any other link worker. The rationale is
that beneficiary would be able to use the cash
assistance for her care during delivery or to meet
incidental expenses of delivery.
Eligibility for Cash Assistance:
LPS States
HPS States
All pregnant women delivering in
Government health centres like Sub
centre,
PHC/CHC/FRU/general
wards of District and state Hospitals
or accredited private institutions. No
age constraint
Role of ASHA or other link health worker
associated with JSY
Along with fulfilling their usual duties of providing anti
natal and post natal care to woman, ASHA/other health
workers would be responsible for
BPL pregnant women, aged 19
years and above
LPS & HPS All SC and ST women delivering in a
government health centre like Sub
centre, PHC/CHC/FRU/general ward
of District and state Hospitals or
accredited private institutions. No
age constraint
>
Identifying pregnant woman as a beneficiary of the
scheme
>
Assisting the pregnant woman to obtain necessary
certifications
>
Identifying a functional Government health centre
or an accredited private health institution for
referral and delivery
>
Escorting the beneficiary women to the health center
and stay with her till the woman is discharged
Limitations of Cash Assistance for
Institutional Delivery:
In LPS States All births, delivered in a health
centre - Government or Accredited
Private health institutions.
Source of Information: Website of Ministry of Health
and Family Welfare
In HPS States Upto 2 live births.
For more Information on need of BPL certification,
Disbursement of Cash
Scale of Cash Assistance for Institutional Delivery
Assistance, flow of
Urban Area
Total
Category Rural Area
Total
fund
(from
state
district
authority
to
Mother’s
ASHA’s
Rs.
Mother’s
ASHA’s
Rs.
ANM to
ASHA),
Package
Package
Package
Package
ASHA’s package under
1000
200
1200
LPS
600
2000
1400
JSY, Subsidizing cost
of Caesarean Section ,
600
700
600
HPS
700
Grievance Redressal
cell, display of names of JSY beneficiaries in health
centers go to: http://mohfw.nic.in/dofw%20website
Generally the ANM/ASHA should carry out the entire
/JSY_features_FAQ_Nov_2006.htm
disbursement process.
8
A Promise of Better Healthcare Services For The Poor
Service Guarantees from Sub
Health Center
>
Correct doses of Vitamin A
>
Prevention and control of childhood diseases like
malnutrition, infections, etc.
(Services provided at the Sub Center are Free
of Cost for a person from BPL family)
Family Planning and contraception
Maternal Health
>
Provision of contraceptives and counseling to adopt
appropriate Family planning methods
>
Counselling and appropriate referral for safe
abortion services (MTP) for those in need
Antenatal care:
>
Early registration of all pregnancies
>
Minimum four antenatal check-ups
>
General examination such as weight, BP, anaemia,
abdominal examination, height and breast examination
>
Iron and Folic Acid supplementation
>
T.T.Injection, treatment of anaemia, etc.
>
Minimum
laboratory
investigations
haemoglobin, urine albumen and sugar
like
Identification of high-risk pregnancies
appropriate and prompt referral
and
>
Adolescent health care
Providing education, counselling and referral services
Assistance to school health services.
Control of local endemic diseases
Disease surveillance
Promotion of institutional deliveries
>
Skilled attendance at home deliveries as and when
called for
>
Appropriate and prompt referral
Disinfection of water sources
>
Promotion of sanitation including use of toilets and
appropriate garbage disposal
Curative Services
Intranatal care:
>
>
>
Provide treatment for minor ailments including
and First Aid in accidents and energencies
>
Appropriate and prompt referral
>
Organizing Health Day at Anganwadi centres at
least once in a month
Postnatal care:
>
A minimum of 2 postpartum home visits
>
Initiation of early breast-feeding within half-hour
of birth
Training, Monitoring and Supervision
>
Counselling on diet and rest, hygiene,
contraception, essential new born care, infant and
young child feeding and STI/RTI and HIV/AIDS
Promotion of exclusive breast-feeding for 6 months
>
Full Immunization of all infants and children
Training of Traditional Birth Attendants and
ASHA
>
Coordinated services with AWWs, ASHA, Village
Health and Sanitation Committee, PRI
Record of Vital events
Child Health
>
>
>
9
Recording and reporting of Vital statistics
including births and deaths, particularly of
mothers and infants
A Promise of Better Healthcare Services For The Poor
>
untied_funds_NRHM.pdf
Maintenance of all the relevant records concerning
mother, child and eligible couples in the area
2) IPHS for Subcenters http://mohfw.nic.in/NRHM/
Documents.TPHS_for_SUBCENTRES.pdf
The Sub Health Centre will be accountable to the Gram
Panchayat and shall have a local Committee for its
management, with adequate representation of Village
Health and Sanitation Committee.
Services Guarantees from Primary
Health Centre (PHC)
ANM and Multi purpose Health worker MPW works
from the Subcentre and deliver the above-mentioned
service with the help of ASHA.
(All services provided at PHC are free of cost
for BPL families)
Every PHC has to provide OPD services. Inpatient
Service, referral service and 24 hours emergency
service for all cases needing routine and emergency
treatment including treatment of local diseases.
Funds
>
>
The Gram Panchayat SHC Committee has the
mandate to undertake construction and
maintenance of SHC. An annual maintenance grant
of Rupees 10,000 will be available to every SHC
All services provided by Sub centers are also
provided by PHC.
Every SHC gets Rs. 10,000 as Untied grants for
local health action. The resources could be used for
any local health activity for which there is a
demand. The fund would be kept in a joint account
to be operated by the ANM and the local Sarpanch
Some additional services provided in a PHC are as
follows:
Maternal Health
Time Line:
> 2 ANM Sub Health Centres strengthened/
established to provide service guarantees as per
IPHS, in 1,75000 places - 30% by 2007, 60% by
2009, 100% by 2010
>
Untied grants provided to each Sub Centre to promote
local health action. 50% by 2007, 100% by 2008
>
Annual maintenance grant provided to every Sub
Centre - 50% by 2007, 100% by 2008
>
Procurement and logistics streamlined to ensure
availability of drugs and medicines at Sub Centres50% by 2007,100% by 2008
>
24-hour delivery services both normal and assisted
>
Appropriate and prompt referral for cases needing
specialist care
>
Pre-referral management (Obstetric first-aid)
>
Facilities under Janani Suraksha Yojana
Family Planning
>
Permanent methods of Family Planning
>
Facility for Medical Termination of Pregnancies
(wherever trained personnel and facility exists)
Treatment of RTI/ STIs
Basic laboratory services
Referral services
Source of Information:
1) Framework for Implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
Appropriate and prompt referral of cases needing
specialist care including:
For more Information go to:
1) Guidelines for VHSCs, SCs, PHCs AND CHCs
http://mohfw.nic.in/NRHM/Documents/GuideIines_of_
>
10
Stabilisation of patient
A Promise of Better Healthcare Services For The Poor
>
Appropriate support for patient during transport
>
Providing transport facilities
Source of Information:
Framework for Implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
A Charter of Citizen’s Health Rights should be
prominently displayed outside all PHCs.
For more Information go to:
Guidelines for VHSCs, SCs, PHCs AND CHCs
http://mohfw.nic.in/NRHM/Documents/Guidelines_of_
untied_funds_NRHM.pdf
The Primary Health Centre (not at the block level) will
be responsible to the elected representative of the
Gram Panchayat where it is located.
Service Guarantees from
Community Health Centre (CHC)
The Block level PHC will have involvement of
Panchayti Raj elected leaders in its management even
though Rogi Kalyan Samiti would also be formed for
day-to-day management of the affairs of the hospital.
The Mission seeks to provide minimum three Staff Nurses
to ensure round the clock services in every PHC.
>
Care of routine and emergency cases in surgery
and medicine
>
24-hour delivery services including normal and
assisted deliveries
>
Essential and Emergency Obstetric Care including
surgical interventions
>
Full range of family planning services
>
Safe Abortion Services
>
Newborn Care and Routine and Emergency Care of
sick children
>
Diagnostic services through the microscopy centers
>
Blood Storage Facility
>
Essential Laboratory Services
>
Referral Transport Services
>
All National Health Programmes should be delivered
through the CHCs. e.g. HTV/AIDS Control Programme,
National Leprosy Eradication Programme, National
Programme for Control of Blindness
Funds
>
>
Each PHC is entitled to get an annual maintenance
grant of Rs. 50,000 for construction and
maintenance of physical infrastructure. Provision
for water, toilets, their use and their maintenance,
etc, has to be priorities. PHC level Panchayat
Committee/Rogi Kalyan Samiti will have the
mandate to undertake and supervise improvement
and maintenance of physical infrastructure
Every PHC is entitled to get Rs. 25,000 as Untied
grants for local health action. The resources could
be used for any local health activity for which there
is a demand
Time Line:
> 30,000 PHCs strengthened/established with 3 Staff
Nurses to provide service guarantees as per IPHS 30% by 2007, 60% by 2009 and 100% by 2010
>
Untied grants provided to each PHC to promote
local health action - 50% by 2007 and 100% by 2008
>
Annual maintenance grant provided to every PHC
- 50% by 2007 and 100% by 2008
>
Procurement and logistics streamlined to ensure
availability of drugs and medicines at PHCs - 50%
by 2007 and 100% by 2008
Over the Mission period, the Mission aims at
bringing all the CHCs on a par with the IPHS to
provide round the clock hospital-like services.
According to IPHS, it is mandatory to display
Charter of Citizen’s Health Rights outside all CHCs.
The dissemination and display of charter is the
11
AYUSH
responsibility of Block Health Monitoring and
Planning Committee.
The term AYUSH covers Ayurveda, Yoga &
Naturopathy, Unani, Siddha and Homeopathy. These
systems are popular in a large number of States in the
country, e.g. Ayurved system is popular in the States of
Madhya Pradesh, Rajasthan, and Orissa, the Unani
system is particularly popular in Tamil Nadu and
Maharashtra.This is to imply that the AYUSH systems
of medicine and its practices are well accepted by the
community, particularly, in rural areas. The medicines
are easily available and prepared from locally available
resources, economical and comparatively safe.
According to IPHS, it is mandatory for every CHC to
have “Rogi Kalyan Samiti” to ensure accountability/
Mission also seeks to provide separate AYUSH set up
in each CHC.
Funds
>
>
Every CHC gets Annual maintenance grant of
Rs. 1 lakh for construction and maintenance of
physical infrastructure. Rogi Kalyan Samiti/Block
Panchayat Samiti has a mandate to undertake
construction and maintenance of CHC
One of the objectives of the mission is to revitalize local
health traditions and mainstream AYUSH into the
public health system.
Every CHC gets Rupees 50,000 as Untied grants for
local health action. The resources could be used for
any local health activity for which there is a demand
Modalities For Integration
>
For mainstreaming, the personnel of AYUSH may
work under the same roof of the Health
Infrastructure, i.e., PHC, CHC; However, separate
space should be allocated exclusively for them in
the same building
>
The Doctors under the Systems of AYUSH are required
to practice as per the terms & conditions laid down for
them by the appropriate Regulatory Authorities
>
Provision of one Doctor of any of the AYUSH
systems as per the local acceptability assisted by a
Pharmacist in PHC
>
Provision of one Specialist of any of the AYUSH
systems as per the local acceptability assisted by a
Pharmacist in CHC
>
Supply of appropriate medicines pertaining of
AYUSH systems
>
The already existing AYUSH infrastructure should
be mobilized. AYUSH dispensaries that are not
functioning well should be merged with the PHC or
CHC barring which, displacement of AYUSH clinic
is not advised
>
Cross referral between allopathic and AYUSH streams
should be encouraged based on the need for the same
Time Line
> 6500 CHCs strengthened/established with 7
Specialists and 9 Staff Nurses to provide service
guarantees as per IPHS-30% by 2007,50% by 2009
and 100% by 2012
>
Untied grants provided to each CHC to promote
local health action- 50% by 2007 and 100% by 2008
>
Annual maintenance grant provided to every CHC
-50% by 2007 and 100% by 2008
>
Procurement and logistics streamlined to ensure
availability of drugs and medicines at CHCs-50%
by 2007 and 100% by 2008
Source of Information:
1) Framework for Implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20 Frame work
%20for%20Implementation.pdf
2) IPHS for CHC(A) http://mohfw.nic.in/NRHM/
Documents/Draft_CHC.pdf
For more Information on Guidelines for Village
Health and Sanitation Committees, Sub Centres. PHCs
and CHCs go to: http://mohfw.nic.in/NRHM/Documents
/Guidelines_of_untied_funds_NRHM.pdf
12
A Promise of Better Healthcare Services For The Poor
>
AYUSH Doctors shall be involved in IEC, health
promotion and also supervisory activities
>
The IPHS pertaining to AYUSH and also the
detailed manpower and other requirements and
financial projections for the same will be provided
by the Department of AYUSH for further
consideration
Source of Information:
Mainstreaming of AYUSH Systems in the National
Health Care Delivery System- Mohfw.nic.in/ayush%
2015th%20march.pdf
For more Information go to:
Website of Department of AYUSH http://indianmedicine.
nic.in/
13
A Promise of Better Healthcare Services For The Poor
constitution and orientation of VHSC. The Untied
grant to be used by this committee for household
surveys, health camps, sanitation drives, revolving
fund etc.
Community Participation in
NRHM
>
A revolving fund for providing referral and
transport facilities for emergency deliveries as well
as immediate financial needs for hospitalization
would also be operated by the VHSC
Some roles of the VHSC
Village Health and Sanitation
Committee (VHSC)
>
Create Public Awareness about the essentials of
health programmes, with focus on People’s
knowledge of entitlements to enable their
involvement in the monitoring
illage level Health and Sanitation Committee
will be responsible for the Village Health
Plans.
>
Discuss and develop a Village Health Plan based
on an assessment of the village situation and
priorities identified by the village community
This committee would be formed at the level of the
revenue village (more than one such villages may come
under a single Gram Panchayat).
>
Analyse key issues and problems related to village
level health and nutrition activities, give feedback
on these to relevant functionaries and officials.
Present an annual health report of the village in
the Gram Sabha
>
Participatory Rapid Assessment to ascertain the
major health problems and health related issues in
the village. Mapping will be done through
participatory methods with involvement of all
strata of people. The health mapping exercise shall
provide quantitative and qualitative data to
understand the health profile of the village
>
Maintenance of a village health register and health
information board/calendar: The health register
and board will have information about mandated
services, along with services actually rendered to
all pregnant women, new born and infants, people
suffering from chronic diseases etc. Similarly dates
of visit and activities expected to be performed
during each visits by health functionaries may be
displayed and monitored by means of a Village
health calendar
>
Ensure that the ANM and MPW visit the village on
the fixed days and perform the stipulated activity;
oversee the work of village health and nutrition
functionaries like ANM, MPW and AWW
V
Composition
The Village Health Committee would consist of:
> Gram Panchayat members from the village
>
ASHA, Anganwadi Sevika, ANM
>
SHG leader, the PTA/MTA Secretary, village
representative of any Community based organisation
working in the village, user group representative
The chairperson would be the Panchayat member
(preferably woman or SC/ST member) and the convenor
would be ASHA; where ASHA not in position it could be
the Anganwadi Sevika of the village.
Training
The members would be given orientation training to
equip them to provide leadership as well as plan and
monitor the health activities at the village level.
Grants available
>
Every village with a population of upto 1500 gets
an annual Untied grant of up to Rs. 10,000, after
14
A Promise of Better Healthcare Services For The Poor
>
Officer - Primary Health Centre and at least one
ANM working in the PHC area
Get a bi-monthly health delivery report from
health service providers during their visit to the
village. Discuss the report submitted by ANM and
MPW and take appropriate action
>
Time Line
Village Health and Sanitation Committee constituted
in over 6 lakh villages and untied grants provided to
them - 30% by 2007, 100% by 2010
Chairperson:
Panchayat
Samiti
member,
Executive chairperson: Medical officer of the PHC,
Secretary: NGO/CBO representatives
Role & Responsibilities
>
Consolidation of the village health plans and
charting out the annual health action plan in order
of priority
>
Presentation of the progress made at the village
level, achievements, actions taken and difficulties
faced followed by discussion on the progress of the
achievements of the PHC, concerns and
difficulties faced and support received to improve
the access to health facilities in the area of that
particular PHC
>
Ensure that the Charter of citizen’s health rights
is disseminated widely and displayed out side the
PHC informing the people about the medicine
facilities available at the PHC, timings of PHC
and the facilities available free of cost. A
suggestion box can be kept for the health care
facility users to express their views about the
facilities. These comments will be read at the
coordination committee meeting to take necessary
action
>
Monitoring of the physical resources like,
infrastructure, equipments, medicines, water
connection etc at the PHC and inform the
concerned government officials to improve it
>
Discuss and develop a PHC Health Plan
based on an assessment of the situation and
priorities identified by representatives of village
health committees and community based
organizations
Untied grants provided to each Village Health and
Sanitation Committee to promote local health action.
50% by 2007, 100% by 2008
Source of Information:
Framework for implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
For more Information go to:
Guidelines for VHSCs, SCs, PHCs AND CHCs
http://mohfw.nic.in/NRHM/Documents/Guidelines_of_
untied_funds_NRHM.pdf
PHC Monitoring and Planning
Committee
This Committee monitors the functioning of Sub
centres operating under jurisdiction of the PHC and
developes PHC health plan after consolidating the
village health plans.
Composition
>
30% members from PRI (from the PHC coverage area;
2 or more sarpanchs of which at least one is a woman)
>
20% members non-official representatives from
VHSC, (under the jurisdiction of the PHC, with
annual rotation to enable representation from all
the villages)
>
20% members representatives from NGOs / CBOs and
People’s organizations working on Community health
and health rights in the area covered by the PHC
>
Share the information about any health awareness
programme organized in the PHC’s jurisdiction, its
achievements, follow up actions, difficulties faced etc.
>
30% members representatives of the Health and
Nutrition Care providers, including the Medical
>
Coordinate with local CBOs and NGOs to improve
the health scenario of the PHC area
15
A Promise of Better Healthcare Services For The Poor
>
Review the functioning of Sub-centres operating
under jurisdiction of the PHC and taking
appropriate decisions to improve their functioning
>
>
Initiate appropriate action on instances of denial of
right to health care reported or brought to the
notice of the committee
Role & Responsibilities
Time Line:
Systems of community monitoring put in place - 50% by
2007 and 100% by 2008.
>
Consolidation of the PHC level health plans and
charting out of the annual health action plan for
the block.
>
Review of the progress made at the PHC levels,
difficulties faced, actions taken and achievements
made, followed by discussion on any further steps
required to be taken for further improvement of
health facilities in the block, including the CHC
>
Analysis of records on neonatal and maternal deaths;
and the status of other indicators, such as coverage
for immunization and other national programmes
>
Monitoring of the physical resources like,
infrastructure, equipments, medicine, water
connection etc at the CHC; similar exercise for the
manpower issues of the health facilities that come
under the jurisdiction of the CHC
>
Coordinate with local CBOs and NGOs to improve
the health services in the block
>
Review the functioning of Sub-centres and PHCs
operating under jurisdiction of the CHC and taking
appropriate decisions to improve their functioning
>
Initiate appropriate action on instances of denial of
right to health care reported or brought to the notice
of the committee; initiate an enquiry if required and
table report within two months in the committee.
The committee may also recommend corrective
measures to the district level
Source of Information:
Framework for implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementa tion.pdf
Block Monitoring and Planning
Committee
This Committee monitors the progress made at the
PHC level health facilities in the block, including CHC
and develops annual action plan for the Block after
consolidating PHS level health plans.
Composition
>
>
>
>
>
30% members representatives of the Block
Panchayat Samiti (Adhyaksha/Adhyakshika or
members with at least one woman)
20% members non-official representatives from the
PHC health committees in the block, with annual
rotation to enable representation from all PHCs
over time
20% members representatives from NGOs/
CBOs and People’s organizations working on
Community health and health rights in the block,
and involved in facilitating monitoring of health
services
Chairperson:
Block
Panchayat
Samiti
representative, Executive chairperson: Block medical
officer. Secretary: NGO / CBO representatives
Time Line:
Systems of community monitoring put in place - 50% by
2007 and 100% by 2008.
20% members officials such as the BMO, the BDO,
selected MO’s from PHCs of the block
Source of Information:
Framework for implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
10% members representatives of the CHC level
Rogi Kalyan Samiti
16
A Promise of Better Healthcare Services For The Poor
District Health Monitoring and
Planning Committee
related information and necessary steps required
to correct the discrepancies
>
Progress report of the PHCs emphasising the
information on referrals utilisation of the services,
quality of care etc.
>
Contribute to development of the District Health
Plan, based on an assessment of the situation and
priorities for the district. This would be based on
inputs from representatives of PHC health
committees, community based organisations and
NGOs
>
Ensuring proper functioning of the Hospital
Management Committees
>
15% members non-official representatives of block
committees, with annual rotation to enable
successive representation from all blocks
Discussion on circulars, decisions or policy level
changes done at the state level; deciding about
their relevance for the district situation
>
20% members representatives from NGOs/CBOs
and People’s organizations working on Health
rights and regularly involved in facilitating
Community based monitoring at other levels
(PHC/block) in the district
Taking cognizance of the reported cases of the
denial of health care and ensuring proper
redressal
Time Line:
Systems of community monitoring put in place- 50% by
2007 and 100% by 2008.
This Committee contributes to the development of
District Health plan.
Composition
>
30% members representatives of the Zilla Parishad
(esp. convenor and members of its Health
committee)
>
25% members district health officials, including
the District Health Officer/Chief Medical Officer
and Civil Surgeon or officials of parallel
designation, along with representatives of the
District Health planning team including
management professionals
>
>
>
10% members should be representatives of
Hospital Management Committees in the district
>
Chairperson: Zilla Parishad representative,
preferably convenor or member of the Zilla
Parishad
Health
committee,
Executive
chairperson: CMO/CMHO/DHO or officer of
equivalent designation, Secretary: NGO/CBO
representatives
Source of Information:
Framework for implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
State Health Monitoring and
Planning Committee
This Committee reviews and contributes to the
development of State Health plan.
Role & Responsibilities
>
Discussion on the reports of the PHC health
committees
>
Financial reporting and solving blockages in flow of
resources if any
>
Infrastructure, medicine and health personnel
Composition
>
17
30% of total members should be elected
representatives, belonging to the State legislative
body (MLAs/MLCs) or Convenors of Health
committees of Zilla Parishads of selected districts
(from different regions of the state) by rotation
A Promise of Better Healthcare Services For The Poor
>
15% would be non-official members of district
committees, by rotation from various districts
belonging to different regions of the state
>
20% members would be representatives from State
health NGO coalitions working on Health rights,
involved in facilitating Community based
monitoring
>
25% members would belong to State Health
Department
>
Secretary’ Health and Family Welfare, Commissioner
Health, relevant officials from Directorate of Health
Services (incl. NRHM Mission Director) along with
Technical experts from the State Health System
Resource Centre/Planning cell
>
would be discussed an appropriate action initiated
by the committee. Any administrative and
financial level queries, which need urgent
attention, will be discussed
10% members would be officials belonging to other
related departments and programmes such as
Women and Child Development, Water and
Sanitation, Rural development
>
The Chairperson would be one of the elected
members (MLAs)
>
The executive chairperson would be the Secretary
Health and Family Welfare
>
The secretary would be one of the NGO coalition
representatives
>
Institute a health rights redressal mechanism at
all levels of the health system, which will take
action within a time bound manner. Review
summary report of the actions taken in response to
the enquiry reports
>
Operationalising and assessing the progress made
in implementing the recommendations of the
NHRC, to actualize the Right to health care at the
state level
>
The committee will take proactive role to share any
related information received from GOI and will also
will share achievements at different levels. The
copies of relevant documents will be shared
Time Line:
Systems of community monitoring put in place - 50% by
2007 and 100% by 2008.
Source of Information:
Framework for implementation http://mohfw.nic.in/
NRHM/Documents/NRHM%20-%20Frame work
%20for%20Implementation.pdf
Rogi Kalyan Samiti (RKS)
Role & Responsibilities
>
The main role of the committee is to discuss the
programmatic and policy issues related to access to
health care and to suggest necessary changes
>
This committee will review and contribute to the
development of the State health plan, including the
plan for implementation of NRHM at the state
level; the committee will suggest and review
priorities and overall programmatic design of the
State health plan
>
For efficient management of Health Institutions
NRHM has proposed Rogi Kalyan Samiti
(RKS)ZPatient
Welfare
Committee/Hospital
Management Committee (HMC) . This initiative
is taken to bring in the community ownership in
running of rural hospitals and health centres,
which will in turn make them accountable and
responsible.#
Broad Objectives of RKS#
Key issues arising from various District health
committees, which cannot be resolved at that level
(especially relating to budgetary allocations,
recruitment policy, programmatic design etc.)
18
>
Ensure compliance to minimal standard for facility
and hospital care
>
Ensure accountability of the public health
providers to the community
A Promise of Better Healthcare Services For The Poor
>
Upgrade and modernize the health services
provided by the hospital
>
Supervise the implementation of National Health
Programme
>
Set up a Grievance Mechanism System
Grants
To motivate the states to set up RKSs, a support of
Rs.5.0 lakhs per rural hospital, Rs.1.00 lakh per CHC
and Rs. 1.00 per PHC per annum would be given to
these societies through states. The societies would be
eligible for these grants only where they are authorized
by the States to retain the user charges at the
institution level.*
Apart from this, RKS at PHC and CHC will have the
mandate to undertake and supervise improvement and
maintenance of physical infrastructure. RKS would
also develop annual plans to reach the IPHS
standards.*
Time Line*:
> Rogi Kalyan Samitis/Hospital Development
Committees established in all CHCs/Sub
Divisional Hospitals/ District Hospitals - 50% by
2007, 100% by 2009
RKS would be a registered society. It may
consists of following members#
>
>
Group of users i.e. people from community
>
Panchayati Raj representatives
>
NGOs
>
Health professionals
One time support to RKSs at Sub Divisional/
District Hospitals - 50% by 2007, 100% by 2008
Source of Information:
1) Framework for implementation (*) http://mohfw.
nic.in/NRHM/Documents/NRHM%20%20Framework%
20for%20Implementation.pdf
2) Guidelines for IPHS for CHC(A)
According to IPHS, it is mandatory for every CHC
to have “Rogi Kalyan Samiti” to ensure
accountability.A
3) Guidelines for Rogi Kalyan Samiti (#) http://
mohfw. nic. i n/NRHM/RKS. htm
19
A Promise of Better Healthcare Services For The Poor
including safe delivery. The RKS would develop
annual plans to reach the IPH standards.*
Time line*
In the first six months since the launch of the mission,
following work should have been completed:
Some Frameworks for
Community Monitoring
Indian Public Health Standards (IPHS)
PHS are being prescribed to provide optimal expert
care to the community and to achieve and maintain
an acceptable standard of quality of care. These
standards help in monitoing and improving the
functioning of public health centers.#
I
IPHS for CHCs provides for “Assured services” that
should be available in a Community health centre
along with minimum requirements for delivering these
services such as:
> Minimum clinical and supporting manpower
requirement
>
Equipments
>
Drugs
>
Physical Infrastructure
>
Charter of Patients’ rights
>
Requirement of quality control
>
Quality assurance in service delivery-standard
treatment protocol#
>
Selection of and 2 CHCs in each State for
upgradation to IPHS
>
Release of funds for upgradation of two CHCs per
district to IPHS
>
2 ANM Sub Health Centres strengthened/
established to provide service guarantees as per
IPHS, in 1,75000 places- 30% by 2007, 60% by 2009
and 100% by 2010
>
30,000 PHCs strengthened/established with
3 Staff Nurses to provide service guarantees as
per IPHS - 30% by 2007, 60% by 2009 and 100%
by 2010
>
6500 CHCs strengthened/established with 7
Specialists and 9 Staff Nurses to provide service
guarantees as per IPHS - 30% by 2007, 50% by
2009 and 100% by 2012
Source of Information:
1) Framework for Implementation (*) http:// mohfw.nic
.in/NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
2) IPHS for CHC (#) - http://mohfw.nic. in/NRHM/
Documents/Draft_CHC.pdf
For more Information go to:
Link given on Ministry of Health and Family Welfare
website: http://mohfw.nic.in/NRHM/iphs.htm
Similar standards are being developed for PHCs & Sub
Center.*
Charter of Citizen’s Health Rights
Over the Mission period, the Mission aims at bringing
all the CHCs on a par with the IPHS in a gradual
manner. In the process, all the CHCs would be
operationalized as first Referral Units (FRUs) with all
facilities for emergency obstetric care. *
Charter of Citizen’s Health Rights seeks to provide a
framework which enables citizens to know.
It will be for the States to decide on the configuration of
PHCs to meet IPH Standards and offer 24X7 services
20
>
What services are available?
>
The quality of services they are entitled to.
A Promise of Better Healthcare Services For The Poor
>
Emergency Obstetric care
The means through which complaints regarding
denial or poor qualities of services will be
addressed.#
Basic neonatal care for new born
Full coverage of services related to childhood
diseases/health conditions
A Charter of Citizen’s Health Rights should be
prominently displayed outside all District Hospitals,
CHCs and PHCs. While IPHS makes the display
mandatory for every CHC.*
Full coverage of services related to maternal
diseases/health conditions
The dissemination and display of charter is the
responsibility of Health Monitoring and Planning
Committee at that level. E.g. Block Health Monitoring
and Planning Committee has the responsibility to
ensure display of the charter at CHC.*
Full coverage of services related to low vision and
blindness due to refractive errors and cataract.
Full coverage for curative and restorative services
related to leprosy
While the Charter would include the services to be
given to the citizens and their rights in that regard,
information regarding grants received, medicines and
vaccines in stock etc. would also be exhibited.
Similarly, the outcomes of various monitoring
mechanisms would be displayed at the CHCs in a
simple language for effective dissemination.*
Full coverage of diagnostic and treatment services
for tuberculosis
Full coverage of preventive, diagnostic and
treatment services for vector borne diseases
Full coverage for minor injuries/illness (all
problems manageable as part of standard
outpatient care upto CHC level)
The charter seeks to increase transparency that would
help the community to bettei- monitor the health
services.*
Full coverage of services inpatient treatment of
childhood diseases/health conditions
Source of Information:
1) Framework for implementation!*) http://mohfw.nic
.in/NRHM/Documents/NRHM%20-%20Framework
%20for%20Implementation.pdf
Full coverage of services inpatient treatment of
maternal diseases/health conditions including
safe abortion care (free for 50% user charges from
APL)
2) IPHS for CHC(#)- http://mohfw.nic.in/NRHM/
Documents ZDraft_CHC.pdf
Full coverage of services for Blindness, life style
diseases, hypertension etc.
For more information go to:
Link given on Ministry of Health and Family Welfare
website: http://mohfw.nic.in/NRFIM/iphs.htm
Full coverage for providing secondary care services
at Sub-district and District Hospital
Concrete Service Guarantees
Full coverage for meeting unmet needs and spacing
and permanent family planning services
Concrete Service Guarantees that NRHM provide are
the benchmarks against which mission functioning can
be monitored and its success can be measured. These
guarantees are as follows:
Full coverage of diagnostic and treatment services
for RI/STI and counseling for HIV-AIDS services
for adolescents
>
Health education and preventive health measures
Skilled attendance at all Births
21
A Promise of Better Healthcare Services For The Poor
60% by 2009 and 1007c by 2010.
Time Line:
SHCs/PHCs/CHCs/Sub Divisional Hospitals/ District
Hospitals fully equipped to develop intra health sector
convergence, coordination and sendee guarantees for
family welfare, vector borne disease programmes, TB,
HIV/AIDS, etc.-30% by 2007, 50% by 2008, 707c by 2009
and 100% by 2012
Source of Information:
Framework for Implementation http://mohfw.nic.in
/NRHM/Documents/NRHM%20-7o20Framework
%20for%20Implementation.pdf
For more information on:
Institution wise service guarantees go to Annex-Ill of
Framework for Implementation.
Institution-wise assessment of performance against
assured service guarantees carried out-30% by 2008,
22
A Promise of Better Healthcare Services For The Poor
Annexure
Model Citizens Charter for CHCs and PHCs
1. Preamble
Community Health Centres and Primary Health Centres exist to provide health care to every
citizen of India within the allocated resources and available facilities. The Charter seeks to provide
a framework which enables citizens to know.
■
what services are available?
■
the quality of services they are entitled to.
■
the means through which complaints regarding denial or poor qualities of services will be
addressed.
2.
Objectives
n
to make available medical treatment and the related facilities for citizens.
□
to provide appropriate advice, treatment and support that would help to cure the ailment to
the extent medically possible.
■
to ensure that treatment is best on well considered judgment, is timely and comprehensive and
with the consent of the citizen being treated.
□
to ensure you just awareness of the nature of the ailment, progress of treatment, duration of
treatment and impact on their health and lives, and
a
to redress any grievances in this regard.
3.
Commitments of the Charter
□
to provide access to available facilities without discrimination.
■
to provide emergency care, if needed on reaching the CHC/PHC.
■
to provide adequate number of notice boards detailing the location of all the facilities.
□
to provide written information on diagnosis, treatment being administered.
a
to record complaints and designate appropriate officer, who will respond at an appointed time,
that may be same day in case of inpatients and the next day in case of out patients.
4.
Component of service at CHCs
□
access to CHCs and professional medical care to all.
□
making provision for emergency care after main treatment hour whenever needed.
23
A Promise of Better Healthcare Services For The Poor
■
informing users about available facilities, costs involved and requirements expected of them
with regard to the treatment in clear and simple terms.
■
informing users of equipment out of order.
■
ensuring that users can seek clarifications and assistance in making use of medical treatment
and CHC facility.
■
informing users about procedures for reporting in-efficiencies in services or nonavailability of
facilities.
5.
Grievance redressal
■
grievances that citizens have will be recorded.
■
there will be a designated officer to respond to the request deemed urgent by the person
recording the grievance.
■
aggrieved user after his/her complaint recorded would be allowed to seek a second opinion
within the CHC.
■
to have a public grievance committee outside the CHC to deal with the grievances that are not
resolved within the CHC.
6.
Responsibilities of the users
■
users of CHC would attempt to understand the commitments made in the charter.
■
user would not insist on service above the standard set in the charter because it could
negatively affect the provision of the minimum acceptable level of service to another user.
■
instruction of the CHC’s personnel would be followed sincerely, and
■
in case of grievances, the redressal mechanism machinery would be addressed by users
without delay.
7.
Performance audit and review of the charter
■
performance audit may be conducted through a peer review every two or three years after
covering the areas where the standards have been specified.
24
Published on behalf of
Advisory Group for Community Action
by
National Secretariat on Community Action - NRHM
Population Foundation of India (PFI)
&
Centre for Health and Social Justice (CHSJ)
3-C, First Floor, H-Block, Saket, New Delhi - 110 017.
Tel.: +91 11 40517478 Telefax: +91 11 26536041
E-mail: chsj@chsj.org Website: www.chsj.org
■
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Janani Shishu S uraksha
Karyakram (JISSK)
Janani Shishu Suraksha Karyakram (JSSK)
ENTITLEMENTS FOR SICK NEWBORN TILL
30 DAYS AFTER BIRTH:
•
Government of India has launched Janani Shishu Suraksha
•
Free and zero expense treatment
Karyakaram (JSSK) on 1st June, 2011 which entitles all
• Free Drugs and Consumables
pregnant women delivering in public health institutions to
•
absolutely free and no expense delivery, including caesarean
• Free Diagnostics
section.
• Free Provision of Blood
It stipulates that all expenses related to delivery in a public
• Free Transport from Home to Health Institutions
institution would be borne entirely by the Government and
•
Free Transport between facilities in case of referral
“Drop Back from Institutionstohome
• Exemption from all kinds of UserCharges
Diagnostics
no user charges would be levied. This will also eliminate any
out of pocket expenses.
•
ENTITLEMENTS FOR PREGNANT WOMEN:
• Free and zero expense Delivery and Caesarean Section
The scheme is estimated to benefit more than 12 million
process of child birth. Both essential and desirable investigations
institutions every year in both urban & rural areas, and also
are required to be conducted free of cost for the pregnant
increase access to health care for the over 70 lakh women
women during ANC, INC, PNC up to 6 weeks. The same are also
delivering at home.
needed when a neonate is sick and needs urgent and priority
The brief details on the entitlements are:
treatmentfor conditions like infection, pneumonia, etc.
Drugs and consumables
Diet
Dr^s & consumables including supplements such as Iron Folic
The first 48 hrs after delivery are vital for
Acid are required to
detecting any complications and its
W
• Free Essential Diagnostics (Blood, Urine tests and Ultra
sonography etc)
• Free Diet during stay in the health institutions (up to 3
days for normal delivery & 7 days for caesarean section)
• Free Provision of Blood
• Free Transport from Home to Health Institutions
• Drop Back from Institutions to home after 48hrs stay
• Exemption from all kinds of User Charges
and likely problems which the women can face during the
pregnant women & newborns that access public health
• Free Drugs and Consumables
• Free Transport between facilities in case of referral
During pregnancy, childbirth and in post natal period,
investigations are essential for timely diagnosis of complications
be given free of cost to
immediate management. Care of the mother
the pregnant women
and baby (including immunization) are
during ANC, INC, PNC
essential immediately after delivery and at
up to 6 weeks which
least up to 48 hrs. During this period,
includes management
mother is guided for
of normal delivery, C-
initiating breast feeding
section and
any
and advised for extra
complications during
calories, fluids and
the pregnancy and
adequate rest which are
childbirth. The same is also needed when a neonate is sick and
needs urgent and priority treatment.
needed for the well being of the baby and herself. Non availability
of diet at the health facilities demotivates the delivered mothers
from staying at the health facilities and most of the mothers
prefer returning home
transport facility to the pregnant women for normal delivery, C-
immediately after delivery.
section. This also needs to be provided to a neonate up to 30
This hampers adequate care of
days, when the baby is sick and needs urgent and priority
the pregnant women and
treatment particularly for conditions like infection, pneumonia,
neonates, which is important
etc.
for quality PNC services.
A drop back facility alleviates the pressure to leave the health
Blood
facility earlier than desirable & obviates out of pocket expenses.
Blood transfusion may be
The free referral transport entitlements for pregnant women and
required to tackle emergencies
sick neonates up to 30 days & therefore are as under:
a^^zomplication of deliveries
1.
Transportfromhometothehealthfacility
2.
Referral to the higher facility in case of need
etc.
3.
Drop back from the facility to home
Exemption from user charges
Most of the States are placing 108 & 102 toll free numbers for
such as management of severe
anaemia, PPH and C sections,
easy access to the referral services.
User charges are levied by many State Governments for OPD,
admissions, diagnostic tests, blood etc. These add up to the out
Grievance Redressal
of pocket expenses. On occasion, there are situations where
these pregnant women are misguided and become vulnerable
For any Grievance related to JSSK:
for exploitation by private diagnostic centres for unnecessary
•
The Hospital In Charge at Hospital level
•
District CMO at district level
•
Mission Director at State level
investigations.
Referral transport
It is well proven that a significant number of maternal and
i
wfri wiwi PffH
IEC Division
Ministry of Health and Family Welfare
Government of India
Designed & Printed a l Batra Art Pre
n^natal deaths could be saved by providing timely referral
- Media
RF_COM_H_92_SUDHA.pdf
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