REPORTS OF THE WORKING GROUP ON HEALTH FOR THE ELEVANTH FIVE YEAR PLAN (2007-2012)
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REPORTS OF THE WORKING GROUP ON
HEALTH FOR
THE ELEVANTH FIVE YEAR PLAN
(2007-2012)
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REPORTS OF THE WORKING GROUP ON
HEALTH
FOR
THE ELEVANTH FIVE YEAR PLAN
(2007-2012)
\JOUJAAC No.
.
GOVERNMENT OF INDIA
PLANNING COMMISSION
2006
SI. No. _____________________________ Title___________________________
Report of the working group on Health Informatics Including Telemedicine
1
for 1 lthFive Year Plan_____
Report of the working group) on Public Health Services (including Water &
2
___ \ i i u»r?Sanitation)^
for the 11 thFive Year Plan
_________________________
Report of the working group on Health of Women and Children for the
3
1111Five Year Plan
4
1
5
6
3
Pages
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WORKING GROUP SERIAL No. WG11
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REPORT OF
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GOVERNMENT OF INDIA
PLANNING COMMOSSION
AUGUST 2006
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Content
SI. No.
Subject
Page No.
1
Planning Commission Order forming the Working Group on
Health Informatics including Telemedicine (WG-HITm) for the
XI Five Year Plan (2007-12).
1-3
1.1
List of Members / Contributors of WG-HITm.
4-6
2
Proceedings of the Meetings of the WG-HITm held on:
7-14
(a) 5th July 2006
(b) 1st August 2006
3
Formation of Two Sub-groups of WG-HITm and their TORs
15-17
(a) Subgroup -1 on Health informatics
(b) Subgroup - II on Telemedicine_______________________
Report of Subgroup -1
4
■ Introduction
■ X Five Year Plan focus
■ Initiatives undertaken during X Five Year Plan
■ Major thrust areas suggested/recommended during XI
______ Five Year Plan _______________ _____ _____ _
Report of Subgroup - II
5
■ Introduction
■ X Five Year Plan focus
■ Initiatives undertaken during X Five Year Plan
■ Major thrust areas suggested/recommended during XI
______ Five Year Plan________________________________
Financial Requirement - Outlay for XI Five Year Plan along with
6
Annual Plans ______________________________________
Annexures:
I
Brief on Integrated Disease Surveillance Project (IDSP)
II
Reports and Recommendations for Improving and Strengthening
Health Information System August 2004, Dte, GHSZ MOHFW,
Govt, of India, _________ __________________________ _
Case study (2004-2005) Improving & Strengthening the use of
ICD 10 and Medical Record System in India - Reports and
Recommendations________________________________ ____
Brochure on Health Sector Policy Reform Options Database (HSPROD)
______________
MOHFW/GOI concept paper on Telemedicine including
Statewise location & progress of telemedicine projects in India.
III
IV
V
18-35
36-51
52-55
56-63
64-71
72-78
79-82
83-95
Annexures
I.
Brief
on
Integrated
Surveillance Project (IDSP).
Disease
IL Major Reports and Recommendations
for Improving and Strengthening
Health Information System August
2004, Dte. GHS/ MOHFW, Govt, of
India.
III. Case study (2004-2005) Improving &
Strengthening the use of ICD 10 and
Medical Record System in India Reports and Recommendations
IV. Brochure on Health Sector Policy
Reform Options Database (HS-PROD)
V. MOHFW/GOI concept paper on
Telemedicine including State wise
location & progress of telemedicine
projects in India.
I
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Constitution of Working Group
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On
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Health Informatics including
Telemedicine
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(WG-HITm)
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WG 11
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No. 2(19)/2006-H & F.W
Government of India
Planning Commission
(Health, Family Welfare & Nutrition)
Yojana Bhawan
Sansad marg
New Delhi
J.5M^ay 2006
ORDER
Subject: Constitution of Working Group on Health Informatics including TeleMedicine for the Eleventh Five Year Plan (2007-2012)
In the context of formulation of the Eleventh Five Year Plan (2007-12) it has
been decided to set up a Working Group on Health Informatics including TeleMedicine under the Chairmanship of •Director General of. Health Services. Ministry of
Health & Family Welfare, Government of India. The composition of the Working Group
is as follows:
| Chairman j
1.
Director General of Health Services, Ministry of Health & Family
Welfare, New Delhi
2.
Secretary (Health), Government of Himachal Pradesh
Member I
3
Secretary (Health) Govt, of Andhra Pradesh
Member
4.
Representative of. Andaman & Nicobar Islands Administration
Member
Shri Rajeev Lochan, Director (Health), Planning Commission, New
Delhi
_______________ .
Member
Shri K.M. Gupta, Director, Miriistry of Finance, New Delhi
Member
Representative, Communication & Information Division, Planning
Commission, New Delhi.
.
Member
! 8 Representative of Indian Council of Medical Research, New Delhi
i 9.’ Representative of Ministry of Information & Technology &
Member
i___
i
I 7.
Member
Communication, New Delhi
i 10.
Member
Representative of Department of Space, New Delhi
hr Representative of
Registrar General & Census Commissioner of
Member
India, New Delhi
I 12.
Representative ,of Apollo Hospital, New Delhi (Telemedicine)
I 13-
Chief Director:(M&E); Ministry of Health & Family Welfare; New
I
Delhi
| 14.
Director, North Eastern Indira Gandhi Regional Institute of Medical
Sciences, Shillong
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■• ■
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Member
Member
' '
Member
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Dr. Arvind Pandey, Director, National Institute of Medical Statistics,
ICMR, New Delhi
__________________
Member
Ms. Ganga Murthy, Economic Adviser. Ministry of Health & Family
Welfare. New Delhi_____________• • • •
__________
Member
Dr. (Mrs.) M. Bhattacharya, Head of Departnient of Community
Health Administration, National Institute of Health & Family
Welfare, New Delhi
Member
18
Member
Dr. Shashi Kant, Professor, Centre for Community Medicine, AllIndia-lnstitute -of-MediGal-SGienGesrNew Delhi---------- ---------------- r
19
Dr. K.K. Aggarwal, Past President Delhi Medical Association, New
Delhi
________ _____ ______________ ________
Member
i 20
Dr. Y.P.Gupta, Health & IT Consultant, New Delhi
Member
21
i 22
Representative. EPOS Health Consultants, New Delhi
Member
2,
Director, Central Bureau of Health Intelligence, Ministry of Health & Member
Secretary
Family Welfare, New Delhi
The Terms of reference of the Working Group will be as under:
(i)
(N)
(iii)
(iv)
(v)
To assess the availability and quality of data, their accuracy and
reliability and problems in making estimates. Methods for improvement
in 11th Plan period.
To review the present Health Management Information System(HMIS),
its capability to provide up-to-date information for effective timely
response to policy makers & implementing agencies so as to make
HMIS an integral part of National Rural Health Mission.
To suggest modification in policies, priorities and programmes during
11th Plan period , New initiatives arid strategies such as tele-medicines
etc., so to improve quality and coverage of services at affordable cost
and also cope with existing, reemerging and new • challenges in
diseases, emerging problems of non-communicable diseases due to
increasing longevity, life style changes arid environmental degradation;
To indicate Manpower requirement and financial outlays required for
implemehtation of these programmes during the i I1’1 Plan period.
To deliberate and give recommendations on any other matter relevant
to the topic.
3.
The Chairman may form, sub-groups and co-opt official or non-official members
as needed. The' Steering Committee will submit Its report by 31st August, 2006.
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4.
Shri Rajeev Lochap, Director. (Health), Room No. 463, Planning Commission,
Yojana Bhawan, New Delhi will be the Nodal Officer for all further communications.
5.
The expenditure on TA/DA in connection with the meetings of the Steering
Committee in respect of the Official members will be borne by the parent Department
2
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/Ministry to which the official belongs as per the rules of entitlement applicable to them.
The non-official members of the Steering Committee will be entitled to TAZDA as
permissible to Grade I officers of the Government of India under SR 190 (a) and this
expenditure will be borne by the Planning Commission
K
(Rajeev Lochan)
Director (Health)
Tel. No. 23096711
Is
--------- ------------ ------ ---------------------------— ----- -- ----- ---------- —-hQchan@nic:.in,._
To: The Chairman and all Members of the Working Group.
Copy to:
1. PS to Deputy Chairman/MOS
(Planning)/Members(KP)/(AS)/(VLC)/(BLM)/(BNY)/(AH)Z(SH)/Member-Secretary.
Planning Commission, Yojana Bhawan, New Delhi
2. All Pr. AdvisersZAdvisersZ
AdvisersZAdvisers/ HODs in Planning Commission
3. Prime Minister's Office, South Block, New Delhi
4. Cabinet Secretariat, Rashtrapati Bhawan, New Delhi
5. US(Admin.l) Z Pay & Accounts OfficerZ Accounts-I Section, Planning Commission
Z DDO, Planning Commission
6. Information Officer, Planning Commission
&
(Rajeev Lochan)
Director (Health)
■
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LIST OF MEMBERS of WG-HITm for XI Five Year Plan
Name And Address
1. Dr.R K Srivastava Chairman
Director General of Health Services
M/o Health & Family Welfare
Nirman Bhawan, New Delhi-110011_________
2. Dr. Arvind Pandey,
Director National Institute of Medical Statistics
ICMR, Ansari Nagar, New Delhi-110029_____
3. Sh. P. Chattopadhyay,
Chief Director (M&E),
MOHFW, Nirman Bhawan, New Delhi -110011
4. Sh. B.S.Bedi,
Scientist “G” HOD,
Deptt. of Information & Technology
M/o Communication & IT, New Delhi-110003.
5. Ms. Ganga Murthy
Economic Adviser,
MOHFW
Nirman Bhawan, New Delhi-110011_________
6. Sh. L.S. Satyamurthy,
Programme Director (Telemedicine)
Deptt. of Space, Hqr. IRSO
Antrix Bhavan, Bangalore-560094.
7. Prof. K. Ganpathy, Head
Apollo Telemedicine Networking Foundation,
Chennai-600006.________________________
8. Dr. (Prof) Sashi Kant,
AIIMS, Ballavgarh,
Faridabad, Haryana-121004.______________
9. Dr. R. K Sharma,
Director, NEIGRIMS,
Shillong,
Meghalaya-793012._____________________
10. Dr. M. Bhattacharya, HOD (CHA)
Community Health Admn.
NIHFW,
New Delhi—110067____________________
11. Dr. D Bachani,
Programme Officer IDSP
NICD,
22, Sham Nath Marg, Delhi-110054
(011)23061438
dghs@nic.in
12. Dr. Sudhir Gupta, CMO,
Dte.GHS
Nirman Bhawan,
New Delhi-110011
(011)-23061980
cmoncd@nic.in
4
i
Phone/e mail
(011)-26588803
arvindpandey@vs nl.net
(0ll)-23062699
cdstat@nb;nic.in
24360582,9868243335
bedi@mit.gov. in
(011)23062744
gangamurthy@gmail.com
080-22172187, 3415459,
098451417905
lsaty@antrix.org
044-28295447
drkganapathy@gmail.com
0129-2211227
skant76@hotmail.com
0364-2004681
neigri@sanchamet.in
(011)26165959
cha_nihfw@yahoo .co .in
(011)23932290
idsp-npo@nic.in
f
13. Sh. Vidhya Prakash, Dy. RGI (SRS)
O/o RGI, West Block I, Wing 1
R.K. Puram, Sector-1
New Delhi-110066_____________ _
14. Ms. Rugimini Parmar,
Director (PF-II)
Deptt. of Expenditure
M/o Finance, New Delhi-110001
15. Mr. Rajeev Shanna,
Addl. Director,
Director of Health Services, Swasthya Sadan
Himachal Pradesh, Kasumpti, Shimla-171005
16. Dr? Y. P. Gupta,
Health & IT Consultant
West Shalimar Bagh, New Delhi-110088
26. Dr. M.R. Surwade,
Head (PH)
EPOS, A-69, Ground floor,
Hauz Khas, New Delhi-110016
18. Dr. K. Satyanarayana
Sr. DDG(P&I Division)
ICMR, Ansari Nagar New Delhi-110011
19. Mr. K.L. Gupta,
Dy. Director (NRHM)
Director of Health Services,
Swasthya Sadan, Himachal Pradesh,
Kasumpti,
Shimla-171005_______________________
20. Representative of Secretary (Health)
Andaman & Nicobar Island-744101
21. Mr. Rajeev Lochan Director (Health)
Planning Commission,
New Delhi-110001________________
22. Dr. (Mrs.) Jagdish Kaur,
Chief Medial Officer (JK),
352, Nirman Bhawan,
Directorate General of Health Services,
Nirman Bhawan,
New Delhi-110011____________________
23. Sh. M.M. Chanda,
Joint Adviser (C&I),
Planning Commission,
New Delhi-110001________________ _
24. Principal Secretary (Health)
Department of Health, Medical & F. W.
Govt, of Andhra Pradesh,
A.P. Secretariat,
Hyderabad-500 022
5
(011)26104012
vP_58@yahoo.com
(011)23092761
rugmini.p@nic.in
0177-2625060
raju 1510@yahoo.co.in
(011)27485578
yg@ygconsultants.com
(011)26963946
drsurwade@epos. i n
(011)26589258
kanikaram_s@yahoo. com
Ph: 0177-2623429,
09418060164
03192-234880
raj endra@and.nic.in
(Oil) 23096711
rlochan@nic.in
(011)23063120
j agk2001 @red i ffmai 1 .com
(011)23096759
mmchanda@nic. i n
mmchanda@yahoo.com
040-23455824
prisecy_hmfvv@ap.gov.in
25. Dr. K. K. Agarwal, Ex-President
Delhi Medical Associaton
S-344, GK-I, New Delhi-110048
26. Dr Ashok Kumar
Dy. DG & Director
Member Secretary
Central Bureau Of Health Intelligence,
Dte. General Of Health Services,MOHFW
Nirman Bhawan, New Delhi-110011.
(011)41620701,41620702
drkk@ijcp.com
(011)-23063175
dircbhi@nb. nic. in
Officers of CBHI Co-opted to Support
27. Shri P K Mukhopadhyay
Joint Director
Central Bureau Of Health Intelligence,
Dte. General Of Health Sendees,MOHFW
Nirman Bhawan, New Delhi-110011.
28.Shri Anirudh kr Singh
Assistant Director
Central Bureau Of Health Intelligence,
Dte. General Of Health Services,MOHFW
Nirman Bhawan, New Delhi-110011.
♦ ******:♦:*
6
(0U)-23062695
dircbhi@nb. nic. in
(011)-23062695
d ircbhi@nb. nic. in
Proceedings of the
Meetings of
WG-HITm held on
5th July
and
1st August 2006
7
2.
The subgroup should emphasize how it can be an integral part of the
National Rural Health Mission (NRHM) launched by MOHFW in
April 2005.
i
3.
The set of formats for collecting information should be simplified.
4.
A World Bank supported study on IT Infrastructure on Health is
presently being conducted by EPOS — a brief about this study will be
presented by Dr. Surwarde in the next meeting.
The next meeting of Sub Group I has been fixed on 17th July 2006, 1100 hrs in
the office of its convener.
In the meeting of Sub Group II, convened by Mrs. Gangamurthy, Economic
Adviser, Ministry of Health & FW, following major points emerged:
1. Medical Council of India should make it mandatory to include at least 20 hrs
syllabous in application of IT in health care delivery system. It should be for all
the Doctors, and All the medical workers involved in health care delivery.
2. There should be training and teaching for the general physicians in IT
Application in Health sector.
i
3. Training and Capacity building in private and Public Sector in Health care and
I
I
IT delivery.
4. There should be at least one National Training institute and 4-5 Regional
Training institutes. The students from DTs should also be trained in the
application of IT in Health Sector.
5. National Institute of Health Information should be set up.
6. Trauma is one of the major emerging public health problems.
7. There should be integration of all the existing information on health related field. The
website of the MOHFW should be the repository of the health information. The
information should come from all the sources to the Central repository.
8. There should be identification of all the Shortcomings.
9. There should be standard protocol available foe the general public.
The next meeting of Sub Group II to be held on 12th & 24th July 2006 in the
office of the convener.
The meeting ended with vote of thanks.
**:****
10
Second Meeting of Working Group on Health Informatics including Tele-Medicine
(WG-HITm) for the Eleventh Five Year Plan (2007-12), under the chairmanship of
Dr. R.K. Srivastava, DGHS was held on 1.8.2006 (1100-1330 hrs) at Committee
Room (No. 249 A), Nirman Bhawan, New Delhi.
While welcoming all the participants, the chairman requested the Member Secretary to
summarise the activities & progress of working group, so far. Dr. Ashok Kumar,
Member Secretary briefed about the summary of first meeting already communicated
to all members arid formation & TORs of two sub groups on 5.7.2006 itself viz. Sub
group I (Convener Dr. Arvind Pandey, Director NIMS, ICMR) and Sub Group II
(Convener Ms. Gangamurthy, Economic Adviser, MOHFW/GOI) and the meetings
of these two sub groups and he then requested Ms. Gangamurthy, Convener Sub
Group-II to present the report of her group.
While presenting & sharing the report of Sub Group-II, Ms. Gangamurthy explained
about the developments that has already taken place in the field of telemedicine during Xth
Five Year Plan, existing gaps, and the recommendations of this group for the eleventh five year
plan. She also briefed about the setting of National Task Force on Tele-Medicine in
MOHFW/GOI. She however, infoimed that this sub group has not yet finalized about the
manpower and financial requirement that can be incorporated after the report of the National
Task Force on Telemedicine under the chairmanship of Union Secretary (HFW/GOI),
which is likely to be finalized by 14.8.2006. While clarifying the query of the chairman
Sh. L.S. Satyamurthy, the expert from ISRO shared the experiences in tele
consultation system that has been implemented on the pilot basis in different states like
Karnataka, Tamil Nadu, Kerala, Rajasthan, Chhattisgarh etc. He explained the need of the
project to be operationalised now along with capacity building for this purpose that can be taken
up in the next five year plan. Prof. K. Ganapathy from Apollo Telemedicine Networking
f
Foundation informed about the development in technologies which can be useful not only for
tele-consultation but also for tele-treatment with proper training to the service providers.
Chairman desired that capacity building exercise should be taken to properly utilize the existing
telemedicine facilities. Dr K K Aggrawal, former DMA President, stressed the need to of eprescription as it is already in practice in USA. Mr. M M Chanda, Director (I&T) from
planning Commission was of the view that students from all the engineering and
polytechnic colleges should be trained in application of IT in health sectors.
11
The chairman also shared his experience in telemedicine .while he was working with
SGPGIS wherein the objective was the text and graphic trasfer which ended up as text
transfer only. He also stressed the need of further discussions in this issue with Dr. B.S. Bedi,
Deptt. of FT; representative from C-DAC, Govt, of Himachal Pradesh and West Bengal on the
initiative taken in telemedicine and this meeting can be organized in his office immediately. The
chairman further expressed the need of preparing a doable model, keeping in mind the financial
and the physical capacity of the country. He requested the experts of this Working Group
to further debate on this issue and come up with a suggestive planned document. He
f
informed that the National Task Force will definitely cover all this aspects but
this group should identify those gaps on telemedicines including tele-consultation
c
and tele-treatment with suggested solutions which might have already been taken by some
individuals efforts. The technological and the legal issues must be kept in mind while
(
developing the model. The model should setup the goals which may include the plan for
successive five year plans also and move in this direction in a phased manner. He observed that
at this stage, during Eleventh Five Year Plan, it may be difficult to go below district level. He
requested to come up with the planned document involving the financial outlay which is
feasible and can be afforded by the Planning Commission. Further he stressed on the need
for holistic treatment including Standard treatment protocol, health education, related
regulatory Authority, working through the system having dedicated Satellite involving
all the stakeholders. He talked about ideal situation wherein there should be a dedicated
satellite but we have to see our resources. The chairman desired that we can have different goals
like for 10 yrs, 15 yrs, 20 yrs goals. He further stressed that our targets should be fixed keeping
in mind what is the scope of improvement in TI sectors as well. What are the likely advances
which is likely to take place. Dr. Ganapathy also informed that while developing the financial
outlay, the contribution from private sectors may also be incorporated and he hoped that around
20% of this outlay could be contributed by the private hospitals.
Dr. Arvind Pandey, the convener of SubGroup-I presented & shared the reports and
recommendations of Sub Group-!.- This sub group met twice, on 5.7.2006 and again on
17.7.2006 to finalise the report. He briefly presented about the historical background of HMIS
which was introduced during the Eighth Five Year Plan by CBHI. However, this could not
take off due to some major problems like (i) maintenance of registers and formats (ii)
inadequate facilities of NIC (iii) Non availability of any legal provision for collection of
data from Non Govt, sector etc. He then described about the developments taken during
the Xth Five year plan
I
period (2002-07).
The National Statistical Commission
recommended a comprehensive Assessment of the Health Management Information
12
I
System (HMIS) by a small committee. Accordingly MOHFW constituted a committee under
the chairmanship of DGHS with 13 members from MOHFW/GOI, Planning Commission and
NIC with Director CBHI as the Member Secretary. This committee after due deliberations
recommended that Integrated Disease Surveillance Project (IDSP) launched by MOHFW
should be further strengthened and efficient health information system from periphery
with computer/server facilities at each district and State/UT and with due flexibility to
State/UT to incorporate local information in the system. There is a need to integrate
HIMS and IDSP with an appropriately designed information format and indicators at
various levels of health care delivery for an appropriately timely corrective measures.
He also briefed about the development of IDSP since November 2004, the disease
covered under it and its satellite communication system viz. EDUSAT with 800
Satellite Interactive Terminals.
He also emphasized about the report of National
Commission on Macroeconomics and Health on “Building a Health System for
Improving Health Information System - The Way Forward”. This report recommended
establishment of a National Institute of Health Information & Disease Surveillance
comprising of economics, public health specialists, epidemiologists, doctors etc. This institute
should have additional fund for research and capacity building to develop a skilled health work
force for policies in an objective manner. He also briefed about the National Rural Health
Mission and their goals. He then briefed about the recommendations of this sub group on:
•
Reduction of the loan of MPW (female) at the sub center level in filling up
registers etc.
•
Creadon of more CHCs in the country.
•
Unified formats under NRHM for monitoring of information and evaluation
system.
•
Strengthening of HIS with its proper linkage with IDSP.
•
Creation of National Institute of Health Information System and capacity
building of health manpower.
The chairman observed that this group should very clearly analyse the failure of HMIS
and the basic reasons may be the obsession of the management in collecting information which
are irrelevant and redundant. At the sub center level, the grass root level worker were loaded
with large volume of registers and formats which ultimately was the reason for not taking
up the work load and there was very little support from NIC regarding electronic data
transmission system.
13
He explained that for all planning purposes, fixing of targets for our work plan, the
I
Health Information System is extremely important. At present, neither IDSP nor CBHI
is able to do justice to HIS. He insisted that we must learn from our earlier failures and
design the plan for Health Information System in Eleventh Plan in a more realistic
manner. He felt the need of support from Donor Agencies like World Bank, WHO,
UNICEF, UN Agencies etc. in developing a successful model for HIS. He also gave a
practical demonstration with the Form No. 6 related to Family Welfare programme and
described about various indicators that are redundant and should be deleted while
collecting information at the grass root level. He said that at every level like district,
state and at national level, the health indicators must be determined and accordingly the
data should be collected while keeping in mind removing all redundant components in
the data reporting system. Ms. Gangamurthy emphasized the need of HIS for critical
planning. She explained about the change of concept from the outlay budget to the
outcome budget and thus there is a definite need of validated information at every
level. She felt the need of locating State Institutes which can take up the responsibility
of data validation. Mr. P. Chattopadhyay, Chief Director, MOHFW also requested
for creation of manpower who will be responsible for providing validated data from
grass root level to the national level. Dr. Ashok Kumar, Director CBHI emphasized
that at every level starting from district the state machineries need to be mobilized in
Health Information System. He felt that the major issue is the managerial problem in
getting and transmitting this data from periphery upward.
The chairman in his concluding remark expressed his satisfaction about the progress of
WG-HITm & work done so far. However, he also requested both the sub groups to
design their plan in a justified manner and to link with the outcome of the plan. He
requested both the sub groups to concretize and finalise their plan that should also
include the manpower and financial requirement for the Eleventh Plan and finalise the
positively submit their respective sub groups reports to Member Secretary by
11.8.2006. He also emphasized the need of preparing a well documented doable plan
for the Eleventh Five Year Plan.
The meeting ended with the thanks to the chair.
******
14
Formation of Subgroups
& Their TORs
Subgroup-I
On Health informatics
Subgroup-II
On Telelmedicine
1
15
Formation of two Sub Groups
Sub Group -1
(TOR 1) To assess the availability and quality of data, their accuracy and
reliability and problems in making estimates. Methods for improvement in Xlth FYP.
(TOR 2) To review the present Health Management Information System (HMIS),
its capability to provide up-to-date information for effective timely response to policy
makers & implementing agencies so as to make HMIS an integral part of National Rural
Health Mission.
(TOR 4) - To indicate Manpower requirement and financial outlays required for
implementation of these programmes during the 11th Plan period.
I
1. Dr. Arvind Pandey,
Director NIMS - Convener,
ICMR, Ansari Nagar,
New Delhi-110029
Ph: (011)26588803, (Fax) 26589556
E: mail: arvindpandey@vsnl.net
3, Sh. B.S. Bedi,
Scientist uG9t HOD,
Deptt. ofInformation & Technology
M/o Communication & FT
New Delhi-110003.
Ph: (011) 24360582, 9868243335
E-mail: bedi@mit.gov. in
2. Sh. P. Chattopadhyay, CD (M&E),
MOHFW, Nirman Bhawan, New Delhi -110011
Ph: (011)23062699
E-mail: cdstat@nb.nic.in
5. Dr. M. Bhattacharya, HOD (CHA)
Community Health Admn. NIHFW,
New Delhi-110067
Ph: (011)26165959
E-mail: cha_nihfw@yahoo.co.in
6. Dr. (Prof) Sashi Kant,
AHMS, Ballavgarh,
Faridabad, Haryana-121004
Ph: 0129-2211227
E-mail: skant76@hotmail.com
7 Dr. D. Bachani,
Programme Officer IDSP
NICD, 22, Sham Nath Marg, Delhi-110054
Ph: (011)23932290,
E-mail: idsp-npo@nic.in
8. Ms. Rugimini Parmar,
Director (PF - II), Deptt. of Expenditure
M/o Finance, New Delhi-110001
Ph: (011)23092761
E-mail: rugmini.p@nic.in
9. Sh. Vidhya Prakash, Dy. RGI (SRS)
O/o RGI, West Block I, Wing 1
R.K.. Puram, Sector-1
New Delhi-110066
Ph: (011)26104012
E-mail: vp_58@yahoo.com
10. Mr. Rajeev Shanna,
Addl. Director,
Director of Health Services, Swasthya Sadan
Himachal Pradesh, Kasumpti, Shimla-171005.
Ph: 0177-2625060
E-Mail: rajul5l0@yahoo.co.in
11. Dr. Y. P. Gupta, Health & IT Consultant
West Shalimar Bagh, New Delhi-110088
Ph . (011)27485578
E-mail: yg@ygconsultants.com
12. Dr. M.R. Surwade,
Head (PH)
EPOS, A-69, Ground floor,
Hauz Khas, New Delhi-110016
Ph: (011)26963946
E-mail: drsurwade@epos.in
4. Dr. R. K. Sharma,
Director, NEIGRIMS,
Shillong, Meghalaya-793012
Ph: 0364-2004681
E-mail: neigri@sanchamet.in
16
Sub-Group —II
(TOR 3) To suggest modification in policies, priorities and programmes during
11th Plan period, New initiatives and strategies such as tele-medicines etc., so to
improve quality and coverage of services at affordable cost and also cope with ex isting,
re-emerging and new challenges in diseases, emerging problems of non-communicable
diseases due to increasing longevity, life style changes and environmental degradation.
(TOR 4) To indicate Manpower requirement and financial outlays required for
implementation of these programmes during the 11th Plan period.
1. Ms. Ganga Murthy - Convener,
Economic Adviser,
244(B) A Wing, MOHFW,
New Delhi-110011
Ph :(011) 23062744
E-mail: gangamurthy@gmail.com
2. Sh. B.S.Bedi,
Scientist “G” HOD,
Deptt. of Information & Technology
New Delhi-110003
Ph : (Oil)24360582, 9868243335
E-mail: bedi@mit.gov.in
3. Prof. K. Ganpathy, Head
Apollo Telemedicine Networking
Foundation, Chennai-600006
Ph: 044-28295447
E-mail: drkganapathy@gmail.com
4. Sh. L.S. Satyamurthy,
Programme Director (Telemedicine)
Deptt. of Space, Hqr. IRSO
Antrix Bhavan, Bangalore-560094
Ph: 080-22172187, 23415459, 098451417905
E-mail: lsaty@antrix.org________________
6. Dr. D. Bachani,
Programme Officer EDSP
NICD, 22, Sham Nath Marg, Delhi-110054
Ph : (011) 23932290, E-mail: idsp-npo@nic.in
5 Dr. K. Satyanarayana
Sr. DDG (P&I Division)
ICMR, Ansari Nagar New Delhi-110011
Ph:(011)26589258
E-mail: kanikaram_s@yahoo.com
7. Dr. Sudhir Gupta, CMO, Dte.GHS
Nirman B hawan, New Delhi-110011
Ph: (011)23061980
E-mail: cmoncd@nic.in
drsudhirgupta@gmail.com
8. Dr. (Mrs.) Jagdish Kaur,
Chief Medial Officer (JK),
352, Nirman Bhawan, Dte GHS,
Nirman Bhawan^ New Delhi-110011
Ph: (011)23063120
E:mail: jagk2001@rediffmail.com
9. Sh. M.M. Chanda,
Joint Adviser ( C&I)
Planning Commission, New Delhi-110001
Ph: (011)23096759
E-mail: mmchanda@nic.in
10. Mr. Rajeev Lochan Director (Health)
Planning Commission,
New Delhi-110001
Ph: (011)23096711
E-mail: rlochan@nic.in
11 Principal Secretaiy (Health)
Department of Health, Medical & F. W.
Govt, of Andhra Pradesh, A.P. Secretariat
Hyderabad - 500 022Ph : 040-23455824
E-mail: prisecy_hmfw@ap.gov.in
^.Representative of Secretary (Health)
Andaman & Nicobar Is.-744101
Ph: 03192-234880
E-mail: rajendra@and.nic.iri
13. Dr. K. K. Agarwal, Ex-President
Delhi Medical Associaton
S-344, GK-I, New Delhi-110048
Ph: (011) 41620701,41620702
E-mail: drkk@ijcp.com
14. Mr. K.L. Gupta,
Dy. Director (NRHM)
Director of Health Services, Swasthya Sadan
Himachal Pradesh, Kasumpti, Shimla-171005
Ph: 0177-2623429, 09418060164
17
i
Report and Recommendations
of
SubGroup-I
on Health Informatics
for the XI Five Year Plan
10th FIVE YEAR PLAN (FYP) - FOCUS
INITIATIVES TAKEN DURING 10™ FYP
MAJOR THRUST AREAS DURING XI FYP
MANPOWER & FINANCIAL REQUIREMENT
18
Report & Recommendation of Sub Group — I for XI Five Year Plan
In its first meeting of the Working Group on Health Informatics held on 5.7.2006
under the Chairmanship of DGHS, the sub-group I was constituted with Dr. Arvind
Pandey, Director, National Institute of Medical Statistics (NIMS), as the Convener and
other members. This sub-group focused on three terms of references (TORs) of the
Working Group viz. (i) to assess the availability and quality of data, their accuracy
and reliability and problems in making estimates. Methods for improvement in XI
FYP (ii) to review the present Health Management Information System (HMIS), its
capability to provide up-to-date information for effective timely response to policy
makers & implementing agencies so as to make HMIS an integral part of National
Rural Health Mission and (iii) to indicate Manpower requirement and financial
outlays required for implementation of these programmes during the XI Plan
period.
The sub-group I in its meting held on 17.7.2006 discussed at length the present scenario
of the health information, its limitations and inadequacies. It was noted by the sub-group
that accurate, relevant and up-to-date information is essential to health service managers
if they are to recognize the weaknesses in health service provision and take actions that will
improve service delivery. Accordingly, the development of effective information systems is a
necessary precursor to managerial improvement. It was observed that a health management
information system is a process whereby health data (input) are recorded, stored,
retrieved and processed for decision-making (output). Decision making broadly includes
managerial aspects such as the planning, organizing and control of health care facilities at the
national, state and sub-state levels and clinical aspects which can be subdivided into (i) providing
optimal patient care (ii) training of medical personnel to generate appropriate human resources,
and (iii) facilitate research and development activities in various fields of medicine.
Subsequently after the second meeting of the working group held on 1st August 2006 the
chairman expressed his satisfaction about the progress made so far.
However, he also
suggested both the sub-groups to design their plan in a more focused manner linking with the
outcome of the plan. He suggested concretizing and finalising their plan with due inclusion of the
manpower and financial requirement for the Eleventh Plan and submit report by 11 August
2006. Accordingly, a meeting of this subgroup was organized on 8.8.06 to review the
recommendations and to finalise the report of subgroup -1.
19
HMIS is an essential management tool for effective functioning of the health
system. During the Eighth Plan the Central Bureau of Health Intelligence and the state
Bureaus of Health Intelligence developed a HMIS system for sending district level
information on morbidity reported by the government primary health care institutions
through National Informatics district computer network. Though some states responded
initially the system was never fully operationalised in any state. The HMIS system did
not take root due to the several inherent deficiencies. The major problems faced in the
implementation of HMIS were:
a) HMIS proforma requires continuous maintenance of detailed Subcentre Registers,
numbering 13, along with the Reporting formats. This involves substantial recurring
expenditure for printing of forms and registers. The States/UTs expressed inability to
meet the recurring expenditure for printing of forms and registers.
b) Lack of hardware, software and trained personnel at the district and lower levels and the
NIC facilities were inadequate to meet computing requirements of HMIS
c) Separate programme wise Information System - required by some users
d) No legal provisions for collecting data from non-govemment sector.
e) No compulsion at State / UT level to implement the system.
As a result there is no system through which reliable data on morbidity in different
districts/states could be collected and analyzed and used for decentralized district based
planning. So far there has not been any effort to use the currently available IT tools to
build up a comprehensive HMIS and use it to improve efficiency and functional status of
the health system.
2. 10TH FIVE-YEAR PLAN (2002-07) - FOCUS
During the Tenth Plan the focus was to ensure that effective two way management
information system is built up throughout the country; all data pertaining to health and
family welfare programmes to be collected, collated and reported from all districts and
utilized to improve functional status and efficiency of the health system. Efforts would
also be made to build up a fully functional, accurate HMIS utilizing currently available
IT tools; this real time communication link requires to send data on births, deaths,
diseases, drugs, diagnostics and equipment and status of ongoing programmes through
service channels within existing infrastructure and manpower and funding. It also
facilitates decentralized district based planning, implementation and monitoring.
20
The Tenth Plan envisaged a comprehensive review of (a) disease surveillance
programmes which was being implemented in different states under different disease control
programmes and under the project on disease surveillance. Private sector provides over 75% of
curative care. However, data from private health providers is not yet included in any disease
surveillance system, (b) laboratory facilities available for investigation of epidemic prone
diseases and (c) also the reporting systems currently in use. However, health and family welfare
issues continued to follow two different pathways which were far from the concept of integration
necessary for a unified health information system. Efforts also need to be made to integrate the
ongoing programmes for disease surveillance and develop a comprehensive disease
surveillance programme at the district level.
Thus tenth five year plan (2002-07) focused on:
• Building up a fully functional, accurate Health Management Information System
(HMIS) utilizing communication link will send data on births, deaths, diseases, request for drugs,
diagnostics and equipment and status of ongoing programmes through service channels within
existing infrastructure and manpower and funding; it will also facilitate decentralized district
based planning, implementation and monitoring.
•
Building up an effective system of disease surveillance and response at the
district, state and national level as a part of existing health services.
3. INITIATIVES UNDERTAKEN DURING X FIVE YEAR PLAN
3.1 Constitution of National Statistical Commission
The Union Ministry of Statistics & Programme Implementation (MOSPI) during the year 2001
constituted the National Statistical Commission (NSC) under the Chairmanship of Dr. C.
Rangarajan which had articulated the deficiencies observed in the health and family welfare
statistics. It had observed * that as extensive data are being collected by various agencies and
compiled, there exist various problems, deficiencies and gaps. The system was not successful on
account of non-reporting, under-reporting, variable coverage, delays in receipt of reports, data not
being gender-specific and age specific, data not catering to the needs of the general public, etc.
The major problems faced in the implementation of HMIS in the past were lack of
hardware, software and trained personnel at the district and lower levels. The National
Informatics Centre (NIC) facilities were inadequate to meet the computing requirements
* - Report on National Statistical Commission published by M/o SPI2001
21
of HMIS. Further, while the information for various programmes is collected separately
by the peripheral worker and sent upwards from sub-centre, primary health centre and
community health centre to the district and
State levels, there is no coordination between the various health programmes
implemented by the several Departments of Ministry of H&FW. Maintenance of patient
care records is also very poor in most of the Government hospitals. The information from
the private sector is not properly collected and included in the data generated by the
official sources. Most of the States have hot paid attention to implement the programme
due to various reasons including lack of funds and trained manpower resources. As a
result the HMIS has failed to achieve the objectives for which it was set up and has not
functioned satisfactorily.
Due to poor implementation of HMIS by the States, the earlier system of collection of
information by various programme authorities has continued to be in existence along with
HMIS, which has created an undue burden on the peripheral workers as they have to fill up a
number of proforma and maintain a number of records related to various programmes namely,
malaria eradication, goitre, immunisation, MCH, family planning, blindness control, tuberculosis,
AIDS and leprosy.
The Commission observed that a computerised health information system at all treatment
facilities is an essential prerequisite for establishing an effective Health Management
Information System. The HMIS has a good potential to provide a comprehensive database on
working of health programmes at the decentralised level up to the district. The HMIS if properly
implemented would reduce delays in the information flow, provide qualitative information in a
standardised form, avoid duplication and facilitate quick retrieval of information by all agencies
concerned. Some of the key recommendations of the Commission are:
(a) A comprehensive assessment of the Health Management Information System (HMIS)
should be made by a small Committee quickly and HMIS be reintroduced in the country
in a phased manner with necessary modifications. The combined HMIS format should be
separated into programme-wise modules. While revising the programme modules, care
should be taken to meet the data requirements of both the Central and State
Governments. Flexibility should be given to the States and UTs to include
additional items to meet their State specific data requirements.
22
(b) Steps should be taken to rationalise and minimise the number of records and
registers maintained by the peripheral health workers such as ANMs and public
health inspectors to reduce their burden and to improve the quality of data. The
minimum data set on which data from the grass root levels should be regularly
collected along with their periodicity should be clearly identified.
(c) A suitable mechanism to collect the data at the grass roots level and its upward
transmission to the district, State and the National level should be evolved and for
that methods of data collection, transmission, and processing must be modernised.
As NIC facilities are inadequate to meet the requirements of HMIS, adequate
funds need to be provided for necessary hardware, software and connectivity and
training of personnel.
(d) The Central Bureau of Health Intelligence (CBHI), which is at present a part of
Directorate General of Health Services (DGHS) should be separated and
upgraded to a full-fledged Directorate of Health Statistics (DHS) directly under
the Department of Health. An officer from the Indian Statistical Service at the
Additional Secretary level should head this Directorate and act as the Statistical
Adviser to the Ministry. Also required posts of supporting officers should be created.
The DHS should be the nodal agency in matters of health statistics and should advise the
Department in all matters related to the collection of Health Statistics; coordinate with the
National Statistical Office the Central and State Governments as well as international
agencies in matters related to health statistics.
(e) The CBHI upgraded as DHS should be strengthened with adequate Electronic
Data Processing (EDP) personnel and existing personnel should be trained in
EDP operations, to enable the processing, tabulation and presentation of the large
volume of data on health. Adequate funds out of the national health programmes should
be earmarked for development and maintenance of information system as well as for
verification of field level performance data through independent agencies.
(f) In order to facilitate effective implementation of the HMIS in the States and UTs,
the State Department of Health and Family Welfare in every State should have a
Statistical Division headed by a senior level statistical officer. In the districts, a
health statistics cell should be set up in the Office of Chief Medical Officer
(CMO) to implement HMIS and to take care of all health and family welfare
statistical activities of the district.
23
3.2
Constitution of a committee by MOHFW/GOI to review HMIS & its
recommendation
Accordingly, Union M/o Health & Family Welfare constituted a Committee* under the
chairmanship of DGHS with 13 members from MOHFW/GOI, CSO, Planning Commission and
NIC and Director CBHI as the Member Secretary, with the following terms of references:
I. Comprehensive Assessment of HMIS for re-introduction with modifications and
schedule of re-introduction in phased manner.
II. Separation of combined format into programme-wise modules.
III. Flexibility of States/UTs to include additional items to meet States specific data
requirements.
IV. Setting up of detailed action plan with definite milestones and target dates for
implementation of recommendations of National Statistical Commission, keeping in
view result of HMIS assessment.
The committee met twice, on 5.10.2004 and 2.12.2004 and reviewed the HMIS and its
functioning in the country.
Keeping in view of National Health Policy (1983) and to achieve the goal of Health for
AH by 2000 AD through Primary Health Care Approach there was a strong need for efficient
Management Information & Evaluation System in health sector. As a combined effort of
Dte.GHS/MOHFW, State Health Departments, NIC, Planning Commission and WHO (1986-88),
the need based HMIS was developed and field-tested in 1989 in one District each of Gujarat,
Haryana, Maharashtra and Rajasthan. It was only meant to cover rural health services. In a
review meeting during 1989 HMIS found to be satisfactory and merited implementation
throughout the country in phased manner. Also it was decided that the system should be given a
computer compatible format and to operate the same through NICNET in due course.
Accordingly the system was made computer compatible by NIC/ CBHI and PHC/District
Hospital/Private Hospital Formats were developed (HMIS version 2.0) in 1990. During 1992,
under HMIS Ver. 2.0, NIC/CBHI developed thirteen Sub-Centre Registers, three Model
Reporting Formats and Control Charts for PHC & District levels. In all 13 States were included
for HMIS Ver. 2.0 implementation and the States were requested to examine the model formats
and adapt accordingly to specific needs with minimal set of essential information.
In a review meeting held in March 1996 it was observed that only two States (Haryana &
Sikkim) had implemented HMIS 2.0. This review recommended that (i) a task force with
adequate and appropriate representation from various programme and states be constituted which
should inter-alia look into desirability of devising a unified programme by consulting the
existing machinery at sub-centes, PHC, District, State and Central level programme officers to
(*) - Vide Order No. Z - 18021 Z 5/2002 - PH(CBHI) dated 31.12.2003
24
come up with suitable recommendations for changes in the existing formats, (ii) since the
district NIC facilities are inadequate to meet the computing requirements of HMIS, this
set up needs to be suitably strengthened in terms of manpower, equipment and
infrastructure, for meeting the HIS requirements, (iii) also to make the HMIS more
comprehensive and effective, the urban health care system should also be studied, (iv) the training
programmes required more funding and manpower to make the implementation rapid and
effective, and (v) the respective State Governments may consider bringing an Act with a view to
formulate guidelines making it obligatory on the part of private sector, Local Self Govt.
Departments (LSGD) to provide information related to various health services being rendered by •
them.
In a subsequent workshop held in December 1997 on HMIS reviewed the extent of
computerization of distt. Chief Medical & Health Officer & their connectivity to NIC-NET.
Following important recommendations emerged:
0
Computers at NIC district centre are hardly available for entry of HMIS and other
health data. It is, therefore, necessary that the requisite hardware with accessories and
the latest operating softwares are provided to the District Chief Medical Officer and
Directorate of Health Services at State/UT HQrs. with common software.
ii)
The trained personnel may be available at district and state level for operation and
maintenance of computer hardware and softwares. Each programme should have a
component of training in “General awareness to computer, data entry, programming
etc.” at district and state level. The requisite fund may be kept at the disposal of
District Chief Medical Officer and Directorate of Health Services/State Bureau of
Health Intelligence at State/UT HQrs. Distt. Programme Manager to ensure data
entry in Distt. CMHO office computer.
iii)
It was strongly felt that 15% of the total cost of hardware may be earmarked for
annual maintenance and a fixed amount in every district may be provided towards
purchase of computer consumables and other stationery items. There should be a
nodal agency at the national level and also at the state level for all the
programmes responsible for drawing funds from different programmes and
make available the registers and formats.
iv)
HMIS format to be revised to independent programme wise modular formats keeping
in view that the modular formats may be uniform over States/UTs and contain gender
information and also information by specific age groups wherever applicable.
v)
NIC to Centrally Develop Data entry software with flexibility for add on
information.
25
This Committee under the chairmanship of DGHS/GOI after due deliberations
observed that over last two decades an appreciable advancements have taken place in the
development of health information systems in India, especially National Health
Programmes like RNTCP, NVBDCP, NBCP, NLEP, etc. have utilized the modem
information technology/software for their information system. The Union Ministry of
Health & Family Welfare after due planning has launched (November 2004) the World
Bank supported Integrated Disease Surveillance Project (IDSP) with cost of more than
Rs.400 Crores and this projects envisages the further strengthened and efficient health
information system from periphery with computer/server facilities at each district and State / UT
and with due flexibility to State / UT to incorporate information in the system.
Under this project, care has been taken to link all the program specific computers
in each district with IDSP server so as to make integration of all health information. With
this advancement and commitment by the MOHFW / GOI, there is a need to integrate
HMIS with IDSP with an appropriately designed information format and indicators at
various levels of health care delivery for an appropriate timely corrective measures.
The final recommendation of this committee was communicated to M/o Statistics
& PI * clearly indicating that “it will be desirable to strengthen this IDSP as a national health
information system with appropriate computer connectivity rather than pursuing the HMIS which
was conceived about two decades back and could not succeed for various reasons. In the present
context, this Union M/o Health & FW is committed to ensure the efficient implementation of
IDSP which is one of the major projects undertaken with World Bank loan. This Ministry is also
tracking the information on financial, logistics, manpower and implementation aspects for
ensuring timely corrective appropriate measures I hope this will suffice fulfilling the need of
aforesaid recommendation of NSC on the subject matter. Your further suggestion will be
appreciated”.
3.3 Launch of Integrated Disease Surveillance Project (IDSP)
Integrated Disease Surveillance Project (IDSP) is a decentralized, State based
Surveillance Program in the country. It is intended to detect early warning signals of
impending outbreaks and help initiate an effective response in a timely manner. It is also
expected to provide essential data to monitor progress of on-going disease control
programme
and
help
allocate
health
resources
more
efficiently.
D.O. letter no. Z -18021 / 5/ 2002 - CBHI dated 28.1.2005 from Union Secretary MOHFW to
Union Secretary, M/o Statistics & PI.
26
The IDSP was launched by Hon’ble Union Minister of H&FW in November 2004 with
following objectives to:
0
Establish a decentralized district based system of surveillance for communicable
and non-communicable diseases so that timely and effective public health actions
can be initiated in response to health challenges in the urban and rural areas while
establishing Public private Partnership.
K)
Integrate the existing surveillance activities (to the extent possible without having a
negative impact on their activities) so as to avoid duplication and facilitate sharing
of information across all disease control programmes and other stake holders, so
that valid data are available for decision making at district, state and national levels.
A brief on IDSP indicating (a) diseases covered in Regular Surveillance, Sentinel
Surveillance, regular Periodic Surveys, State Specific Diseases, (b) Organization
Structure, (c) Training of District Surveillance Teams, (d) Procurement of Goods (e)
Development of software for diseases surveillance (f) Baseline study on Public Health
Laboratories (g) External Quality Assurance System (h) Participation of Private Sector &
Medical colleges (i) NCD Risk Factor Surveillance (j) budget allocated and utilized, are
enclosed at Annexure -1.
3.3.2 IDSP Satellite Communication System
IDSP launched Satellite Linkage on 29lh March 2006 with Central studio at National
Institute of Communicable Diseases with a sub-hub in Nirman Bhawan and 800 Satellite
Interactive Terminals (SITs) located throughout the country would be set up connecting all
the State and Districts Units, Medical Colleges and premier state and national public health
institutions. For a fully functional network, it is also being considered of intervention of
network under National Rural Health Missions and various National Health Programmes.
EDUSAT, a dedicated educational satellite launched by ISRO is being utilized to set
up communication and information network throughout the country'.
Proposal has
been submitted to the World Bank for clearance. This network will be utilized for
distance training programmes, teleconferencing and data transmission. Funds have
been sanctioned from IDSP Budget for 2005-06 to ISRO to cover 400 SITs by June
06. Remaining 400 SITs would be covered during 2006-07 and covered by December
2006.
27
3.4 Constitution of National Commission on Macroeconomics and Health
(NCMH) by Govt, of India
The NCMH in its Report* titled “Building a Health System for Improving Health
in India - The Way Forward” recommended:
■
A National Institute of Health Information & Disease Surveillance needs to be
established as an autonomous body consisting of Board members from other
ministries, statisticians, researchers and State-level policy makers. The Institute must
also have a multidisciplinary composition comprising economists, public health
specialists, epidemiologists, and doctors. Disease burden estimations, National Health
Accounts, cost-effectiveness studies of interventions, efficacy of vertically driven
interventions including ICDS in countering the problem of malnutrition in the country,
independent evaluations of programme implementation are examples of the kind of
work that needs to be undertaken.
■
There is a need of reviewing National health information system at various levels —
Central, State, district and block - by various agencies - different ministries and
departments in the government - method of data flow, gaps in data, utilization of the
data, organizational set up, accessibility of information to various persons at various
levels are aspects to be examined.
■
Alongwith domestic resources, external aid, WHO assistance etc. be fruitfully
utilized for processresearch capacity by earmarking fellowships every year to
institutes of excellence abroad and within India. Of the total 25% must be at the
doctoral level and the rest at the Master’s level. It should be our target to have a pool
of atleast 500 persons with a combination of such critical skills by the end of 2012.
Such fellowships should be open for competition and not be confined to central
government employees of the Ministry of Health. This will help develop capacity and
expertise outside government and be available for policy advise in an objective manner.
3.5 Launch of National Rural Health Mission (NRHM) by Govt, of India
Recognizing the importance of Health in the process of economic and social
development and improving the quality of life of our citizens, the Government of India has
launched the NRHM in April 2005 to carry out necessary architectural correction in the basic
healthcare delivery system. The Mission adopts a synergistic approach by relating Health to
determinants of good health viz. of nutrition, sanitation, hygiene and safe drinking water.
* - Report of National Commission on Macroeconomics and Health - 2005
28
It also aims at mainstreaming the Indian systems of medicine to facilitate health care.
The Plan of Action includes increasing public expenditure on health, reducing regional
imbalance in health infrastructure, pooling resources, integration of organizational
structures, optimization of health manpower, decentralization and district management of
health programmes, community participation and ownership of assets, induction of
management and financial personnel into district health system, and operationalising
Community Health Centres into functional hospitals meeting India Public Health
Standards in each Block of the Country.
The goal of the Mission is to improve the availability of and access to quality health care by
people, especially for those residing in rural areas with specific objectives:
•
Reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR)
•
Universal access to public health services such as Women’s health, child health, water,
sanitation & hygiene, immunization, and Nutrition.
•
Prevention and control of communicable and non-communicable diseases,
including locally endemic diseases
•
Access to integrated comprehensive primary healthcare
•
Population stabilization, gender and demographic balance.
•
Revitalize local health traditions and mainstream AYUSH
•
Promotion of healthy life styles
The NRHM seeks to provide effective healthcare to rural population throughout the
country with special focus on 18 states, which have weak public health indicators and/or weak
infrastructure. These 18 States are Arunachal Pradesh, Assam, Bihar, Chhattisgarh, Himachal
Pradesh, Jharkhand, Jammu & Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh,
Nagaland, Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh.
3.6 Constitution of Task Force on HMIS by Union Ministry of Health &
FW
A Task Force on HMIS was constituted by the Ministry of Health & Family Welfare during
March, 2006 * under the chairmanship of DGHS with the TOR’s to:
(a) Suggest a format of reporting from Districts and States that could capture health
information required for purposes of planning, monitoring and review.
(b) Suggest the manpower structure at District, State and national levels for a
commonly agreed system of data collection, data entry and data analysis.
29
(c) Agree on the formats of data collection at various levels and its analysis.
(d) Reconfigure the system of statistics and data gathering at the national level to provide for
a more effective and efficient internal organization that meets the requirements of States.
(e) Develop illustrative structures of coordination among various health data interventions
including IDSP at district and State levels.
(f) Weed out unwanted data collection systems and replace them with a consolidated and
comprehensive data system; which can thus satisfied the need.
This task force in its two meetings held till date, viewed the HNfiS of different states like Tamil
Nadu, Rajasthan, Gujarat and Chattisgarh through their detailed presentations as well as
through video conferencing. This task force is in the process of deliberation and is expected to
come out with its recommendations on the above TORs by end of August 2006.
3.7 In depth Review with all the States/UTs for Improving & Strengthening Health
Information System & use of ICO 10 and National Recommendations
In order to ensure electronic data flow and further improve the efficient Health Information
System (HIS), CBHI had held (a) training workshop of States/UTs for sensitizing them on
electronic data transmission, October 2003, and (b) followed by four regional workshops with
the State/UTs for improving and strengthening the Health Information System during 2002-2004.
The Combined Report & Recommendation** (Annexure-II) of the above said workshops
were communicated to all State/UT health authorities for necessary action. This was pursued by
CBHI officers who visited 18 states/UTs upto peripheral level to make an “on the spot”
situation analysis & supportive supervision for efficient HIS.
During 2005, two national
workshops were organized to review the action plan of all the States/UTs to implement the above
said national recommendations.
During 2006-07, CBHI has planned with selected states to concretize their District specific
action plan to improve & strengthen HIS upto peripheral level, while involving Private Public
Partnership and also study for electronic flow of health information from peripheral to
district/state/national level.
CBHI undertook a case study of 20 hospitals belonging to Central Govt, State Govt, Local
Bodies, Private Sector in cities of Delhi and Rohtak, during years 2004 & 2005 with the objective
to identify the status of implementation of ICD 10, the major constraints and their feasible
solutions to improve and strengthen the use of ICD 10 as well as medical record department in
the country. The important recommendations of the case study are (i) Capacity Building
and Trained Manpower development for using ICD 10, (ii) ensuring administrative actions
to ensure and improved use of ICD 10 in all medical & health institutions in the country and
(*) Vide order no. N-23011/13/2006-Policy dated 233.2006
(**) Combined Reports & Recommendation published by CBHI in August 2004
30
(iii) establishment of World Health Organisation Collaborating Centre for Family of International
Classifications on Diseases & other Health Related Aspects for South East Asia Region in India,
in CBHI. .
The Executive summary & major recommendations (Annexure-IH) * of this case study
have been communicated to all States/UTs health authorities & others concerned for
prompt implementation.
3.8 Health Sector Policy Reform Options Database (HS-PROD) with website
address www.prod-india.com
HS-PROD is a Health Sector Reforms Database. On request of the Donor Coordination Division,
MOHFW, GOI; CBHI after getting due approval from Director General of Health Services has
allotted a Project of high national importance on “Health Sector Policy Reform Option Database
(PROD) of India” which is being supported by European Commission through its Sector
Investment Plan (SIP) with an estimated budget provision of Rs.84 lakhs (approx.). Already 152
entries have been uploaded in the website prod.india.com and this site is being brought to
MOHFW/GOI through NIC. The brochure detailing on HS-PROD is placed as Annexure IV.
4.
MAJOR THRUST AREAS SUGGESTED/RECOMMENDED DURING
XI FYP
1.
While prioritizing Efficient Health Information System (HIS), to begin the States/UTs
should strengthen the existing State/UT health statistics unit in their respective health &
FW directorates with identified nodal officers, trained personnel and computer so as to
effectively coordinate for validated health data base & capacity building in State/UT &
closely link with CBHI.
Subsequently States/UTs to make efforts for establishing a
dedicated State/UT Health Statistics Division, equipped with adequate infrastructure. This
Division be responsible for efficient HIS, validated health database of the State/UT,
monitoring & evaluation as well as capacity building, while keeping close linkages
with CBHI and various reporting unit within the State/UT.
2.
At district level. Chief Medical & Health Officer is responsible for all health statistical
activities under whom the existing Distt Health Statistics cell be strengthened by the
States/UTs and efforts be initiated to equip this cell with a dedicated trained officer as its
incharge and a Group C staff oriented in computer operation and atleast one computer with
accessories. This Distt. Health Information Unit can then coordinate for efficient health
information system in the district, including on the spot supervision and related capacity
building of PHCs & other Health units in the district.
* - Report & Recommendations Published by CBHI, 2006.
31
3.
At PHC/CHC/Dispensary level, the States/UTs should make efforts to orient & reorient
the medical officers and health supervisors towards health data management through
continued supportive supervision and wherever necessary through in service training
program organized by State/UT, CBHI and other Institutions. A close coordination with all
the existing govt./non govt, health institutions in respective jurisdiction will ensure
maximum coverage of health & medical data with requisite quality & timeliness.
4.
Since ANMs at grass root levels are heavily loaded due to their multitasking operations it
is necessary to reduce their workload by providing two MPW(F) in each sub-centre as per
IPHS requirements. They should be given the responsibility of maintaining registers for all
health and family welfare related database. The acute shortfall of MPWs* (64211 out
of sanctioned strength of 81561) has been a cause of concern not only to provide basic
health services but also to document the quantifiable services as a pivot for health
management information system. Similarly there is an urgent need on part of all the
States/UTs to fill in all the post of MPW (male) at both, Sub-Centre and PHC levels, that
will be responsible for collection of health related information.
5.
There is a acute shortage of CHCs too. To maintain the norm of having one CHC
per 1,00,000 population, the present requirement is at least 7415 CHCs, against only 3043
CHCs. Moreover, in the 3,043 CHCs that we do have, only 440 have a pediatrician, only
704 have a physician, only 780 have a gynecologist and 781 a surgeon. So not only is the
infrastructure inadequate, we don't even have the staff to use the existing infrastructure.
Such a large shortfall in medical and paramedical personnel has got an important bearing
on the low priority of the documentation of the information, which should on priority basis
be attended by all concerned state/UT and central level health authorities.
6.
Central & State/UT Governments may bring an act for compulsory registration of all
private/non govt, medical institutions and practitioners with the State/UT Govemmentand
mandatory for them to furnish medical/health reports to appropriate Govt. Health Facility in
their vicinity.
7.
For Monitoring of Information & Evaluation System (MIES) an integrated format on
different health indicators is being developed under RCH/NRHM with an aim to ensure
uniformity in the health information collection system. It is expected that this format will
rationalize the information system avoiding the multiplicity of formats, weeding out
redundant information and thus leading to qualitative dissemination with varying
periodicity
* Rural Health Bulletin, 2006, MOHFW/GOI
32
8.
In order to maintain data quality which is required to be used as inputs for any decision
making, the exercise of validation at different levels hardly needs any emphasis. Since
NRHM had already initiated the concept of establishing Programme Management Units at
state and sub-state levels, their involvement in the validation process should be ensured. In
addition, possibilities may also be explored to associate and identify a nodal officer in the
district health offices so as to assume the ownership of data being transmitted from the
district to the state.
)
9.
What is most important is to remove any underlying apathy to collect the health
information and document them with greater speed and accuracy. This can. be achieved by
putting the right people at the right place having a data sense and data use. The States have
got a greater visible role to play to ensure this important aspect of HMIS. To improve the
quality of data, the grassroots level functionaries need to understand the importance
and use of data generated at their level so that the recording and reporting of data by them
could be improved. Also, the monitoring system at all levels need to be strengthened and
emphasis should be on monitoring of all programmes/components, strengthening feedback
mechanism and utilization of data at all levels for monitoring and planning purposes.
States/UTs may ensue all measures to fully utilize the in-service training programs of
CBHI on Health Statistics and Medical Coding (ICD-10) as well as Medical Record
Management, being organized for various categories of medical/non-medical staff involved
in handling medical/health data, for which purpose CBHI communicates its annual training
calendar well in advance to all States/UTs. For this purpose, every State/UT should
prepare district wise inventory of such training needs, people trained and remaining to be
trained and utilize this inventory for promptly recommending the names of untrained
personnel to various CBHI in-service training courses. The GIS mapping is an essential
tool now-a-days. NIC has already developed GIS maps up to the village level. The facility
should be availed by all the State/UT authorities for GIS mapping on various health
indicators.
10.
The Birth and Death Registration System in the country is still way behind and there is an
urgent need to improve the system. The Civil Registration System must be improved and
strengthened. For this purpose the ASHA, recruited under NRHM can also be utilized for
recording & reporting the birth and death cases to the appropriate authority with a suitable
honorarium.
11. The capacity building of the Health manpower starting from grass root level is extremely
essential and allocation of funds for providing the training must be earmarked in this plan
period. The training on the electronic data management system should also be provided in
association with D/o IT and NIC.
33
12.
ICD-10 coding system be implemented throughout the country for comparison at
both, national and international levels and the use of ICD-10 be concurrently
monitored by hospital administration for timely corrective measures at various
levels, including meeting the ICD-10 trained manpower needs.
13.
As already decided by the MOHFW/GOI, it will be desirable to strengthen EDSP as
a national health information system with appropriate computer connectivity rather
than pursuing the HMIS which was conceived about two decades back and could
not succeed for various reasons. In the present context, this Union M/o Health &
FW is committed to ensure the efficient implementation of IDSP which is one of
the major projects undertaken with World Bank loan. Apart from the work on surveillance,
also attempt to collect information on financial, logistics, manpower and implementation
aspects in the health sector.
14.
Like CBHI has developed a central website for health information, the States/UTs may also
initiate efforts to develop similar websites along with district specific health information,
while utilizing the available expertise of state & districts NIC units.
15.
States/UTs may initiate steps towards computerizing the Hospital Information System in
a phased manner to begin with state/regional level hospitals. This will facilitate efficient
hospital database on morbidity & mortality based on ICD-10,
essential for
District/State/National Statistics on morbidity & mortality. Likewise at the grass root level,
on a pilot basis the use of Hand Held Electronic Device can be explored in association with
the Ministry of Information Technology.
16.
A National Institute of Health Information System, as already recommended by NCMH
may be considered, for which purpose, CBHI be properly upgraded with necessary supports
from public health, statistics and national health programmes to play the role effectively.
This institute will also be responsible for Human Resource Development and research
studies. NIMS, ICMR may be involved in taking up evolution studies and operation
research periodically. The recommendation of National Statistical Commission to upgrade
s the CBHI as a full fledged Directorate of Health Statistics as a nodal agency to provide
sufficient inputs on health statistics should be seriously pursued. The M & E division
of the Department of Family Welfare which is responsible for collecting and collating all
Family Welfare information including RCH should be merged in the proposed National
Institute of Health Information System. Keeping in view the recommendations of NRHM,
the synergy between the Health and Family Welfare Information System need to be
made and this Institute should be responsible for Monitoring and Evaluation of all
health related programme including RCH.
34
Report and Recommendations
of
i
SubGroup-II
on Telemedicine
for the XI Five Year Plan
Reflector
Radto
LNB
R«jo ftm- Trantw***
Atet Meehartam
Foccnom
Food UwxnRSSEttM
f
rwd
Struts
J
t
PeMHWUt
I
10th FIVE YEAR PLAN (FYP) - FOCUS
INITIATIVES TAKEN DURING 10th FYP
MAJOR THRUST AREAS DURING XI FYP
MANPOWER & FINANCIAL REQUIREMENT
36
)
REPORT OF SUB GROUP II
The Working Group on Health Informatics including Telemedicine in its first
meeting on 5.7.2006 discussed the terms of reference and time schedule for its
functioning. It was decided in this meeting that the terms of reference would be gone into
in-depth by two sub-groups separately constituted for the purpose. Sub-group-II was
constituted with Mrs Ganga Murthy, Economic Advisor/ MOHFW as Convenor to look
into the following TORs: (i) To suggest modification in policies, priorities and
programmes during 11th Plan period, New initiatives and strategies such as telemedicines etc., so to improve quality and coverage of services at affordable cost and
also cope with existing, reemerging and new challenges in diseases, emerging
problems of non-communicable diseases due to increasing longevity, life style
changes and environmental degradation.(ii) To indicate Manpower requirement
and financial outlays required for implementation of these programmes during the
11th Plan period.
With the area of 32,87,268 Sq km. Population of 1.1 billion, urban-rural divide,
inaccessible hilly regions, islands and many tribal areas, India is an ideal setting for
telemedicine assisted health care delivery. Growing number of medical, paramedical
colleges and schools with lack of adequate infrastructure, learning materials and teachers
needs is a matter of grave concern. E health technology has the potential to create a
national level GRID which can form the backbone to be shared by healthcare providers,
trainers and beneficiaries. A strong fiber backbone and indigenous satellite communication
technology in place with large mass of human potential trained in IT and local presence of
telepathy industry, e health application and implementation should not be a problem technically.
Further a number of pilot projects over last five years with successful outcome stand to its
testimony. A ground work on telemedicine in the country has already been laid with the efforts of
ISRO and Information Technology department partnering with many State Government and
specialty Institutes/hospitals. Policy standardization and infrastructural issues have
already been researched. Professional societies on telemedicine/e health have been active. Print
and electronic media are participating in awareness campaign. However, a country level plan is
long due to steer the Telepathy ship by the Captain (M/o Health & Family Welfare/GOI) with its
crew (technology and healthcare providers/educators) and passengers (citizen) in right direction
(policy, implementation, application, security, social and legal issues) to reach at the
destination (Quality healthcare & wellness).
37
1. Focus & initiatives on telemedicine During 10th Five Year Plan period
The 10th Plan inter-alia had focused on building up a fully functional accurate health
management system, utilizing available IT tools, so as to enable the real time
communication link to send data on births, deaths, diseases, requests for drugs,
diagnostics and equipment, facilitate decentralized district planning, implementation and
monitoring.
•
A strong formulation for telemedicine in the country has been laid by ISRO and the
Department of Information & Technology partnering with many State governments,
hospitals and speciality hospitals. Issues of policy, standardization and infrastructure have
been delved into by them. Professional societies on telemedicine/ e-health are actively
engaged in its development.
Information Technology is now one of the major components of the
technological infrastructure for health management. All sub-sectors dealing with the
generation, transmission and utilization of demographic and epidemiological data such as
bio-informatics, bio-statistics, HMIS and the decision support systems (DSS) are finding
increasing use in health planning and management. The nationwide network of NICNET
provides rapid reporting mechanism for health information; MEDLARS Biomedical
Informatics Programmes provides ready access to medical databases to post graduates
and research workers as well as practicing physicians.
Planning Commission has
provided additional central assistance to the UHSs in Karnataka, Andhra Pradesh, Tamil
Nadu, Punjab and Maharashtra for strengthening of libraries and networking them
through IT. This effort has to be augmented and all medical colleges need to be brought
into the network. .
1.1 Indian Space Research Organisation (ISRO)
ISRO has been actively engaged in applying space technology for healthcare and
education through specific initiatives which include inter-alia:
(a) Providing telemedicine technology and connectivity between remote/rural
hospitals and super-speciality hospital for tele-consultation, treatment and
training of doctors and para-medics.
38
(b) Providing technology and connectivity for continuing medical education between
medical colleges and post-medical institutions/hospitals.
(c) Providing technology and connectivity for mobile tele-medicine units for rural
health camps in the areas of ophthalmology and community health.
ISRO’s experience goes back to more than 2 decades of SatCom Application
Programmes namely “Training and Developmental Communication Channel” (TDCC)
and “Jhabua Developmental Communication Project” (JDCP) for application of SatCom
for rural development. The Telemedicine initiative developed in selected parts of the
country during the past 4 years has been one such effort to reach the Speciality Health
■.y
care to the rural and remote district / trust hospitals. The technology involved the ICT
based system consisting of customized medical software integrated with computer
hardware along with the medical diagnostic instruments and connected through the
telecom medium like ISDN or VSATs at each location. The initial pilot efforts had
adopted point-to-point telemedicine system wherein at a given time one rural end could
have tele-consultation with one specialist end.
The telemedicine software consisted
essentially of store and forward modules for tele-radiology, tele-cardiology and tele
pathology purposes alongwith video-conferencing facility.
With the growing demands of telemedicine facility by various States, C4,
“point-to-
multipoint” connectivity through Local Area Network (LAN) and finally “multi point” to
“multi point” connectivity with Wide Area Network (WAN) with integration of the
facility for Continuing Medical Education requirement have been evolved and
established. ISRO has constantly been upgrading the technology with a view of bringing
down the cost both for the ICT hardware and software. Over more than 1,00,000 patients
have been treated in the ISRO network including the Army network, Mobile Tele
Ophthalmology for rural eye camps, telemedicine services for special situations catering
to the large pilgrim population etc. The aspects of development of business model and
also the involvement of medical Insurance scheme is getting evolved gradually.
1.2 Department of IT, Ministry of Information and Technology
As with ISRO, the DTT has aiso started teie-medicine projects in different parts of the
country. DIT by acting as facilitator has taken initiatives for development of technology,
launching of pilot schemes and standardization of tele-medicine in the country.
the achievements of DIT in this regard include:
39
Some of
(a)
Development of tele-medicine software systems. Under the ongoing C-DAC
project, technology developed has been used for connecting 3 premier
institutions namely SGPGI, Lucknow, AHMS, New Delhi and PGIMER,
Chandigarh using ISDM connectivity.
(b)
Tele-medicine for diagnosis and monitoring of tropical diseases has been
implemented in West Bengal.
(c) An oncology network for providing tele-medicine services in cancer detection,
treatment, pain relief, patient follow-up and continuity of care in peripheral
hospitals of RCCs has been established.
(d) Development of State-wise
telemedicine network based on terrestrial
communication in the State of Himachal Pradesh.
L3 Private Sector
A number of initiatives in tele-medicine have been made in the private sector, SGPIMS,
Apollo Hospitals, Asia Heart Foundation, Escorts and others are presently engaged in
extending consultations through tele-medicine and are conducting regular tele-education,
tele-consultation and tele follow-up sessions with patients.
j
1.4 Initiatives by State Governments
State-wise location & progress of telemedicine projects is at Annexure-III. Several
States have also come up with their own initiatives with the usage of information
technology.
A drug inventory monitoring and control system has been evolved in
Haryana. The med-centre of Haryana is an integrated software project to capture
utilization of medicine inventory data and analysis consumption pattern of various
medicines location-wise to monitor disease occurrence pattern, pilferages and any other
deviation in the functioning of the health institutions. The initiative of personal digital assistant
provided to auxiliary mid-wife in Nalgonda district of Andhra Pradesh is another illustration in
point. Through this device, ANMs could record patient information directly on the PBAs which
enable them to follow up cases, whether of pregnant women for ante-natal care or of children for
immunization.
In electronic format, this data can be also transmitted to higher
administrative levels. (Advantages of better targeting the beneficiaries for ante-natal care
and immunization and identification of high risk population in terms of illness). The tele
doc initiative of the JIVA Institute provides for field health representatives in villages
transmitting health information on mobile phones to doctors who then diagnose and
prescribe treatments according to which medicines are supplied.
40
2. Need for strengthening telemedicine / e-health initiatives in India
Despite the massive public health infrastructure, healthcare in rural areas remains a
critical challenge. The magnitude of healthcare services required in the context of the
existing shortage of medical officers and trained para-medics clearly demonstrate the
■
1
need for strengthening tele-medicine and other e-health initiatives over the next Plan.
The National Rural Health Mission provides an opportunity for taking tele-medicine to
the healthcare facilities at the primary, secondary and tertiary levels of care.
Computerization of health related data would be an essential first step.
With the establishment of about 300 Telemedicine nodes by Govt. / Private / Trust
agencies of which 175 nodes by ISRO all over the country and the experiences gained by
each of the implementation agencies have brought to bear some of the important issues
that needs to be addressed for future implementation strategies for the development of
telemedicine and e-health for augmenting the present healthcare delivery system in the
country.
Internet and mobile communication can enormously enhance connectivity between
grass-root health worker and medical specialists as well as translation and storage of data
from the field through the Centralized units.
Telemedicine aims at equal access to medical expertise irrespective of the geographical location
of the person in need. Recent developments in Information and Communication Technologies
(ICT) have enabled the transmission of medical images in sufficiently high quality that allows for
a reliable diagnosis to be determined by the expert at the receiving site.
Access to many different sources of medical data, usually geographically distributed, and the
■■"l
availability of computer based tools that can extract the knowledge from that data are key
requirements for providing a standard healthcare provision of high quality.
Developments in the integration of bio-medical knowledge, advances in imaging, new
computational tools and the use of these technologies in diagnosis and treatment suggest that
Grid-based systems can make a significant contribution to this goal. In addition to enhancement
of improved access by integration of information, the benefits are raised to a new level, over a
Grid because of multi dimensional access to the information.
Medical informatics is often called healthcare informatics or biomedical informatics,
and forms part of the wider domain of e-Health. Medical informatics optimises the
'1
computer analysis, storage, retrieval and transfer of patient and other health care data.
41
)
3. Lessons Learnt during X Five year Plan:
•
Lack of IT infrastructure in the state governments health administration and the
district/taluk hospital.
•
Non- acceptability of telemedicine/e governance by doctors, patients and the
associated staff due to certain “fear of the unknown” and “fear of loss of opportunity”
which has retarded the speed with which the facility could be established.
•
>
The administrative and financial constraints by the State Health Administration for
supporting the implementation of telemedicine at the District Hospitals.
•
Lack of requisite infrastructure and financial support for establishment of the facility.
•
The cost of the equipments though progressively brought down considerably, is still
expensive for most of the hospitals and the Government establishments.
•
The communication bandwidth cost, presently provided by ISRO’s satellites free of
charge whereas others like BSNL and Private Agencies are charged which is
expensive for most of the Hospitals, Health Centre and even Super Specialty
Hospitals.
•
Need for enhanced public awareness of the advantages of Telemedicine / Tele-health
for medical consultations, treatment and postoperative follow-up.
•
The present Healthcare delivery system in each state has detailed procedures
established long time ago in terms of Medical Administration and practice covering
diagnosis, treatment, drug prescription and distribution, surgery and follow-up.
Continuing Medical Education and Training of Doctors and Paramedics etc., and they
have certain policy and operational guidelines. This requires to be extended or
additionally enunciated for appropriate implementing the technology based healthcare
delivery system of telemedicine / tele-health.
•
The policy aspects related to availability and utilization of information which
constitute medical Information and Communication Technologies (ICT) which
constitute the connectivity need to be integrated with the healthcare delivery system
effectively.
4. MOHFW/GOI has constituted task force vide order no. T 2105/1/2004-NCD in
September 2005 on Tele-Medicine in India for formulation of strategies regarding its
42
applications in Health Sector under the chairmanship of Secretary, Health & Family
Welfare with the following TORs:
1. To work on interoperability - Standards for data transmission; software, hardware,
training etc.
2. To define a National telemedicine Grid and consider its standards and operational
aspects. (The task force needs to consider connectivities to be provided in the next
two-three years, as currently there is certain ad-hocism in this process. Available
bandwidth etc. has to be most efficiently used for obtaining priority connectivites).
3. To identify all players and projects currently involved in telemedicine in India and
evaluate their performance, capacity and replicabilty.
4. To prepare pilot projects for connection of
super speciality hospitals/ medical
colleges with district hospitals and /or CHCs / PHCs specially keeping in the mind to
provide access to remote areas. (The focus would be North-East, J&K, three new
States, other tribal areas and Lakshdeep).
5. To prepare National Cancer Telemedicine Network.
6. To examine possibility of utilization of stand alone centers of the deptt. Of
communication in rural areas.
7. To define standards and structures of electronic medical records and patient data base
which could be accessed on a National telemedicine Grid. For this purpose, the
national task force may constitute sub committees for developing electronic medical
records in various fields.
8. To enable the telemedicine centers in teaching institutions to impart training to all
govt. medical/Dental/Nursing Colleges in 3 years time (as there is a huge shortage of
■'1
teaching faculty).
9. To prepare curriculum and projects for CMEs through telemedicine.
10. To draft a National Policy on ‘Telemedicine and Telemedical Education and to
prepare a central scheme for the 11th plan.
Five subgroups have been formed to look into different matters:
Subgroup I: On Telemedicine Standards.
Subgroup II: For formation of National Telemedicine Grid.
43
Subgroup III-A: To identify players and framing evaluation framework for projects
involved in Telemedicine in India, prepare pilot projects (pending proposals, mobile
services, national medical Colleges network etc.) (TOR 3&4).
Subgroup III-B: For ONCONET INDIA (TOR 5).
Subgroup IV: For utilization of existing tele linkage facility in rural areas by
Department of Communication, Standardisation of e-records, training
and CMEs in telemedicine, human resources- medical informatics.
Subgroup V: For preparation of National Policy on Telemedicine and to prepare central
scheme for 11th FYP.
5. Initiatives Needed on telemedicine During XI Five Year Plan:
All these aspects will need to be carefully addressed in the XI Plan. The action plan
would need to take into account the following:
•
A massive awareness programme to the public, doctors and the hospitals staff -
about the benefits of telemedicine & e-health and its efficacy.
•
A proper inter-departmental coordination and cooperation to ensure adequate
support to the doctors and hospitals for commissioning, operation and maintenance of
the facility.
•
A cost effective business model by which the system can be made self sustainable
over a period of time.
•
Effort by the concerned Industries to ensure availability of the equipments and
facilities at reasonable and affordable costs.
•
Aspects of drugs distribution at the remote hospitals when provided with
teleconsultation/treatment by speciality hospitals.
•
Social aspects of telemedicine covering the licensing aspects of medical practitioners
! agencies including the legal aspects.
•
Aspects of private, public partnership for delivery of health care to the rural and
semi-urban population.
•
An appropriate policy by Government of India to provide bandwidth at affordable
cost.
•
Aspects of Continuing Medical Education & Training for Doctors, Paramedics and
1
Health care workers in the form of separate network.
44
•
Referral hierarchy for medical treatment, disease prevention and health promotion aspects.
♦
Introduction of academic courses on all aspects of Telemedicine / Medical information in
various Engineering and Medical Institutions.
5.1 The National Task Force is recommending a national telemedicine grid which will contain
the following major functions / constituents. The Task Force is already looking into the
connectivity, hardware, software requirements for projection under the 11th Five Year Plan
which could be incorporated in the Report of the Health Informatics Working Group.
Essentially the following is already under consideration of the Task Force:
a. A health portal at the M/o H&FW providing all information related to health
informatics, telemedicine, disease surveillance data, medical care details and other
educational material or information related to specific Indian healthcare system not
available in the internet or hyper link to the internet data repository. This portal will be a
constituent of the national grid for repository of information and guidance.
b. An All India Medical Institution network connecting the various recognised medical
institution, national institutes like PGMER, AIIMS, JfPMER, SGPGI etc., and major
super speciality hospitals (Govt. & Private) in the country for medical education,
exchange of knowledge, CME etc.
c.
An All India Network connecting the various selected district hospitals in the country to
be connected to major super speciality hospitals (Govt. /Trust/ Private) for specialist
referrals for consultation and treatment and also medical informatics, disease
information and health promotion aspects from different states of the country, (super
speciality hospital network).
d. A national network for medical training connecting various agencies in the country and
also establish/integrate similar networks at state levels. (National Medical Training
Network).
5.2 State Telemedicine/e-Health Grids (STG)
As a part of e-health program and digitalisation of health records some of the states have been
operating Telemedicine Networks initiated by ISRO and other agencies like Department of
Information Technology (DIT) under Closed Usage Group (CUG) concept e.g. Chhattisgarh,
Karnataka, and Kerala. Many more states are planning to implement such state level networks.
There is a need to formalise the state Telemedicine networks into standard State Grids for
specific purposes of application and usage like; providing State Health Information,
Monitoring and Surveillance of Disease/Epidemic outbreak, identification and mapping
susceptible areas and population etc., as mandated by MoH&FW for health governance.
45
5.3 National Medical Education Institutions Network (NMEIN)
A National Medical Education Institutions Network if created would act as a useful
resource base for knowledge sharing for Medical Education, Research and training including
CME. The teaching and practical sessions can be configured in live or recorded video, audio and
information data broadcast, accessed on the grid, for an effective learning experience.
5.4 Association / Society / Health portals Network (ASHPN)
Several associations/agencies are hosting and maintaining diverse health portals like
DOCTORYANYWHERE.COM in health care services.
It
is
necessary
to
pool
the
resources
available
with
the
various
autonomous/govemment/trust medical associations like Indian Medical Association (IMA),
Cardiology Society of India (CSI), Neurological Society of India (NSI), Federation of
Gynaecological and Obstetrics Society of India (FoGSI) etc and form an Association/society
/health portals Network.
5.5 Digital Library & Medical Informatics Network (DLMIN)
It is required to establish a Digital Library & Medical Informatics Network, that will be a
network of pooled information in the form of digital library of data bases and Medical/Health
Information that can be accessed through Internet I Intranet and used for administrative/research
and / or clinical purposes.
Some of databases of immediate value would include, but not limited to:
1.
Manuals of illness, diseases, symptoms, and diagnostic tools.
2.
National registry of speciality hospitals and specialists: names, contact
information.
3.
Health education programs and curricular materials.
4.
Medicines: description, side effects, location, costs.
5.
Online journals, abstracts, preprints.
6.
Environmental profiles by state/region
(a)
Locations of safe water supplies.
(b)
Location of polluted sources (symptoms and treatment).
(c)
Location of emergency food supplies.
(d)
Location and description of health services.
(e)
Location of disease outbreaks.
(0
Changing environments.
46
5.6 Disaster Management Support Network (DMSN)
It is required that the health care services in times of disaster can be effectively provided
through establishment of Disaster Management Support (DMS) Network. This network is
required to integrate identified disaster Monitoring Stations (current and proposed) across
the country and provide periodic and timely information both statistical and remedial to
the central station for necessary advice/action through the power of medical informatics
and digital connectivity.
Capacity building:
Thrust of health informatics education should be use of health
information standards, storage of health information in electronic health records and
research and extra collation of health information for better healthcare. Clinicians,
healthcare managers, technologists, researchers would all need to specialize in various
aspects of healthcare technologies. The course for skill development to include,
certificate course in computer application, education framework for general, para-medical
and nursing staff. These course would need to be certified by Medical Council of India.
6. Major thrust areas for 11th Five Year Plan
Focus in the XI Plan should be on:
•
Establishment of e-Health department in M/o H&FW in states D/o H&FW with
support of state IT Department.
•
Computerisation of health care delivery system and health records at state,
institutions, district and taluk / block level for the flow of information over the
network.
•
Computerisation of three tier healthcare system: CHC/PHC & SC.
•
To acquire and implement IT equipments like servers and client systems, multicast
video conferencing facilities, data storage and archival facilities in all the speciality
hospitals, medical institutions and other centres of excellence who will be providing
teaching and training facility.
• To identify agencies within the medical institutions / speciality hospitals / research
institutions to develop content for medical education / CME / training modules.
•
To acquire and implement terrestrial / wireless / satcom technologies required for
various connectivities from taluk / block to district to the state capital.
47
•
To plan for one dedicated medium weight class Communication satellite
(HEALTHSAT) for satcom based connectivity which will have the capability to meet
the broadband connectivity requirements for various applications of the National
Grid.
•
The cost of HEALTHSAT with launch, operations and maintenance of the satellite is
around Rs.400 crores. Apart from this, the various connectivity charges by other
technologies have to be incorporated. The present cost of a standard telemedicine
node including computer hardware/software and video conferencing system is around
Rs.4.0 lakhs at the district hospital level. Whereas at the CHC / PHC level the cost
will be around Rs. I to 1.5 lakhs. . Hence number of nodes which will come up during
the 11th Five Year Plan upto the block level may have to be worked out.
•
All tele-medicine network should evolve around a National tele-medicine grid.
Ultimately, every individual would need to have a unique ID.
•
Formal specific training programmes in tele-health for all levels (grass-root to policy
makers depending on requirements) and facilitate a support system to provide current
- >.
information to doctors in the management of patients through new data bases,
software packages etc.
•
Medical Council of India to include Information Technology in healthcare in the
curriculum of all medical and para-medical degree courses. Information Technology
to be also included in. all IT and MBA courses.
■ 'J
•
Introduce at least one mobile van in each district.
•
Trauma care, ambulance on National Highways to be provided with technology for
transmitting audio-video images using EDGE, GPRS, MMS etc. Pilot studies using tele
medicine and ambulances would be required.
•
Setting up of a Tele -health Corporation of India. Given the highly specialized and technical
nature of tele-medicine, a Tele-medicine Board of India needs to be established under the
•J:
aegis of the Ministry, which will include a set of technical experts with representatives from
major healthcare organizations and NGOs working for tele-medicine. The basic objective of
this Board would be to oversee the growth of tele-medicine, develop R&D tools, provide
software, manage the National tele-medicine grid and interact with international
organizations.
•
E prescriptions at all levels by the end of XII Plan but to cover atleast PHCs and
above during the XI Plan. This will necessitate availability of computers and net
facility at all healthcare facility.
48
1
•
Minimum standards of treatment to be documented and made available on the
Ministry of Health website. Details should be available regarding new drugs, banned
drugs, new indications, list of essential drugs, adverse effects, standard treatment
protocol, drugs of choice etc. Skill, knowledge and care should be the comer stone of
what we strive for.
•
Magnitude of care may vary at different levels but the standard of care to remain the
same. This will be possible once the standard treatment protocols are available and
will help in identifying the kind and nature of drugs to be placed at each level and the
financial requirements for making available these drugs at different health facilities.
•
Synergy amongst all existing initiatives and programmes between different
Departments/Ministries in the area of health:
TCI network being created under Department of IT.
North-Eastern Council initiatives with support from ISRO.
E-govemance initiatives like common service centres under Department of
IT.
Integration of existing infrastructure like CBHI, IDSP, NICD etc. in the
Ministry of Health & F.W. to have proper synergy between them and avoid
duplicacy in data collection, compilation and transmission.
Proposed Tele-medicine project by Delhi Government.
Any other State initiative/Central project which will cater to health needs
and requirements.
Tele-medicine would require minimum bandwidth connectivity which facilitates video
conferencing, image, x-ray, medical transcription etc.
7. Financial and Manpower requirements
Tele-medicine/HeaIth Information Unit upto the District level
The objectives of this would be to facilitate proper data collection, compilation, storage
and facilitate analysis and flow of information. The end objective would be to create the
basic foundation structure and build in future the Tele-medicine grid and take on e-
govemance activities.
49
7.1 Total number of units to be covered under telemedicine programme
SI.
No.
Total
ITEMS
1
District Hospitals
604 (As per NIC website)
2
Government Medical Colleges
115 (Only Govt. Medical College excluding
Trusts, Societies, Pvt.)
36
State Headquarters
3
(Jammu
&
Kashmir
has
twoseparate
Division).
4
"755
Total
7.2. Manpower required and financial Implication
SI. No.
Items
Expenditure
Total cost in a yea
1
I Supervisor
Rs. 10, 000 per month
9.06 Crore
2
I Data Entry Operator
Rs.6500 per month
5.90 Crore
3
Total for the annual Plan
Rs.16, 500 per month
15 Crores
4.
Provision for Xlth five year plan:
80 Cr<
(a) Equipments
Total Cost
ITEMS
SI. No.
Financial assistance for equipments @ Rs. 10 lakh each unit f Rs. 75.5 Crs.
1
units
Maintenance @Rs. 2 lakh per annum/unit X 5 years for 755 un Rs.75.5 Crs.
2
Rs. 151 Crs.
Total
This can be provided in a phased manner (in three years) with a provision of Rs.
50 Crores in annual plan 2007-08, 2008-09 and Rs. 51 Crore in 2009-10
(b) Cost of Computerization at PHC level:
SI. No.
1.
Total Cost
ITEMS
Computer with 5 years on-site maintenance with spares & trainir Rs. 80.90 crores
@ Rs.35, 000 per PHC per annum X 23109 (PHC).
This also can be provided in a phased manner (in two years) with a provision of
Rs. 40 Crores in annual plan 2007-08 and Rs. 41 Crore in 2008-09.
50
(c) Health Channel
There should be one dedicated Health Channel from Doordarshan. It should cover the
areas like Education to UG, PG and Post PG Courses; Education to medical practitioners;
Consultations; News at certain intervals; National programmes, disease forecast, helpline
one hour a day, live OPD etc. It should be made mandatory to all cable operators to
beam this channel.
.
30 minutes programme
«
12 hours per day
•
30 days every month
•
30 X 24 = 720 programmes per month
.
Total cost per month = 720 X 2 lakhs = Rs. 14.40 crores
.
Total cost per year = Rs. 14.40 X 12 = Rs. 172 crores
•
Software development of programme can be for Rs. 100 crores instead of Rs. 172 cores
•
Also equipments = 25 Crores
.
Total cost in the entire plan period = 125 Crores (Entire expenditure to be taken
during the first year of the Plan period)
7.3 Other Expenditure
7.3.1 Digital ECG Machine at District hospitals Rs. 20,000 X 604 Hospitals = 1.2 Crore
7.3.2 Web-site and Content Development = Rs. 5 crores
There should be a national health website covering various aspects like Standard
Treatment Protocols, links to various health related website etc.
7.4 GRAND TOTAL: Rs. 443.2 Crores - for the entire Five Year Plan
Year wise Annual Plan requirement
Year
Amount
2007-08
2008-09
2009-10
2010-11
2011-12
Total
236.2
108.0
67.0
16.0
16.0
443.2
Rs.in Crores
********
51
Financial Requirement
Proposed Outlay for the XI Five Year Plan
Period (2007-012)
In Respect of:
1. Scheme : Strengthen of Health Information and
Monitoring Systems
2. Telemedicine (Scheme yet to be proposed by Union
MOHFW/GOI)
• 1
52
1. Scheme “Strengthening of Health Information and Monitoring
System”
Central Bureau of Health Intelligence a national nodal institution for Health Intelligence,
with the broad objectives to (i) Maintain and disseminate the data on Health Profile of
India, (ii) Facilitate capacity building, human resource development and need based
operational research for efficient Health Information System (HIS) and ICD 10 use.
CBHI in the Ministry of Health &. FW is responsible for this ongoing scheme on
“Strengthening of Health Information and Monitoring System” through its Field
Survey Units and training centers. The six FSUs of CBHI are located in different
Regional Offices of Health and Family Welfare (ROHFW) of GOI at Bangalore, Bhopal,
Bhubaneswar, Jaipur, Lucknow & Patna; each headed by a Dy. Director with Technical
& Support staff, who function under the supervision of Regional Director (HFW/GOI).
Regional Health Statistics Training Centre (RHSTC) of CBHI at Mohali, Punjab and
other Training Centres namely (i) Medical Record Department & Training Centre at
Safdagung Hospital, New Delhi and (ii) JIPMER Pondicherry are responsible for
capacity building and trained manpower development.
In order to achieve the objective^Jthis scheme as well as efficient functioning of CBHI,
while also keeping in view the thrust required to improve & strengthen the health
information system during XI five year plan, the following outlay for the XI five year
plan period (2007-012) has been worked out;
OUTLAY FOR THE XI FIVE YEAR PLAN (2007-12)
(Rs. In lakhs)
YEAR
2007-08
2008-09
2009-10
2010-11
2011-12
Total
PLAN
212.00
207.00
227.00
247.00
272.00
1165.00
NON- PLAN
98.00
93.00
98.00
108.00
118.00
515.00
TOTAL
310.00
300.00
325.00
355.00
390.00
1680.00
Note: This outlay does not include the requirement on “Nationa Health Accounts”,
winch is a separate scheme.
*******
53
2. “Telemedicine”
Under this new initiative, it has been proposed to introduce this facility of telemedicine in
■)
district hospitals, Govt. Medical Colleges and the State Health Directorate. A total
number of units to be covered under telemedicine programme is as follows:
S. No.
Total
Type of the facilities
1
District Hospitals
604 (As per NIC website)
2
Government Medical
115 (Only Govt. Medical College excluding
Colleges
Trusts, Societies, Pvt.)
State Headquarters
36 (Jammu & Kashmir has two separate
3
Division).
4
755
Total
In this scheme, it is proposed to provide one supervisory official and one Data Entry
Operator alongwith equipments for this purpose in the above mentioned 755 units. The
J
manpower requirement and financial implication for this purpose is as follows :
Items
SI. No.
Expenditure
Total cost in a year
i
1 Supervisor
Rs. 10, 000 per month
9.06 Crore
2
1 Data Entry Operator
Rs.6500 per month
5.90 Crore
3
Total for the annual Plan
Rs.16,500 per month
15 Crores
4.
Provision for Xlth five year plan:
80 Crores
The total budget requirement under equipment is as follows :
ITEMS
SI. NoJ
1
Financial assistance for equipments @ Rs. 10 lakh each
Total Cost
Rs. 75.5 Crs.
unit for 755 units
2
Maintenance @Rs. 2 lakh per annum/unit X 5 years
Rs.75.5 Crs.
Total
Rs. 151 Crs.
This can be provided in a phased manner (in three years) with a provision of Rs. 50
crores in annual plan 2007-08, 2008-09 and Rs. 51 Crore in 2009-10
54
This scheme also proposes to provide computers at every PHC
(a) Cost of Computerization at PHC level:
Total Cost
ITEMS
SI. No.
Computer with 5 years on-site maintenance with spares &
1.
Rs. 80.90 crores
training
@ Rs.35,000 per PHC per annum X 23109 (PHC).
This also can be provided in a phased manner (in two years) with a provision of
)
Rs. 40 Crores in annual plan 2007-08 and Rs. 41 Crore in 2008-09.
Taking all the above aspects the year wise Annual Plan requirement for the XI Five
Year Plan will be as follows:
Rs.in Crores
Year
Amount
2007-08
2008-09
2009-10
2010-11
2011-12
Total
236.2
108.0
67.0
16.0
16.0
443.2
'3
NOTE : This outlay is an indicative and the Task Force on Telemedicine in India as
constituted by MOHFW/GOI vide order no. T 2105/I/2004-NCD, September 2005,
under the chairmanship of Union Secretary (Health & Family Welfare) is already in
3
process of working out & recommending with regard to the central scheme on
Telemedicine for the XI Five Year Plan. This task force in its report will present the final
outlay for this scheme.
*********
55
Annexu re -1
Integrated Disease Surveillance Project INDIA
Progress Report- March 2006
INTRODUCTION
1.
Integrated Disease Surveillance Project (IDSP) is a decentralized, State based
Surveillance Program in the country. It is intended to detect early warning signals of
impending outbreaks and help initiate an effective response in a timely manner. It is also
expected to provide essential data to monitor progress of on-going disease control programme
and help allocate health resources more efficiently.
• >
The IDS? proposes a comprehensive strategy for improving disease surveillance and
response through an integrated approach with rational use of resources for disease control
and prevention. Data collected under IDSP would also provide a rational basis for
decision-making and implementing public health interventions. Specific objectives of the
IDSP are:
•
•
To establish a decentralized district-based system of surveillance for
communicable and non-communicable diseases so that timely and effective public
health actions can be initiated in response to health challenges in the urban and rural
areas
To integrate existing surveillance activities (to the extent possible without having a
negative impact on their activities) so as to avoid duplication and facilitate sharing of
information across all disease control programmes and other stake holders, so that valid
data for available for decision making at district, state and national levels.
Regular Surveillance
Vector Bome Disease:
Water Bome Disease
Respiratory Diseases
Vaccine Preventable Diseases
Diseases under eradication
Other conditions
. Other International commitments
Unusual clinical syndromes
(Causing death/hospitalization)
!
Sentinel Surveillance
Sexually
transmitted
diseases/Blood borne diseases
Other Conditions
Regular Periodic Surveys
NCD Risk Factors
1. Malaria
2. Acute Diarroheal Disease (Cholera)
3. Typhoid
4. Tuberculosis
5. Measles
6. Polio
7. Road Traffic Accidents
8. Plague, Yellow fever
9. Menigoencephalitis/ Respiratory Distress
Hemmorragic fevers, other undiagnosed
conditions
10. HIV/HBV, HCV
11. Water Quality
12. Outdoor Air Quality (Large Urban
centers)
13. Anthropometry, Physical Activity, Blood
Pressure, Tobacco, etc.
State Specific Diseases
Each State can include upto 5 diseases prevalent in the State.
56
'I
2.3 Training of District Surveillance Teams (Rapid Response Teams)
Nine training institutes were identified to conduct training of the District Surveillance
Teams. A training module has been developed for use during the training programme.
States were allotted to the training institutions and time frame for various batches is fixed
mutually by the training institutions and the State Surveillance Units. Training of
State/District Surveillance Teams has been completed for 9 States covered under Phase-I
of the Project as indicated below :
No. Trained
Training Institution
States Allotted____________
95_________
NIHFW, New Delhi
Himachal Pradesh, Uttaranchal
113________
Madhya Pradesh___________
NICD, Delhi__________
99_________
NIE, Chennai__________
Tamil Nadu_______________
118________
Kerala, Karnataka__________
CMC, Vellore_________
67_________
Andhra Pradesh____________
JIPMER, Pondicherry
Maharashtra______________
59_________
BJ Medical College, Pune
Maharashtra (Vidharbha)
58_________
GMC, Nagpur_________
41
Mizoram_________________
AIIH&PH Kolkata
650
Total____________________
Training of Phase-II states has begun. Funds for training.of District Surveillance Teams are
released directly to the training institutions based on estimated cost governed by financial norms
prescribed for the Project.
Training Institution
States Allotted___________________ No. of Trainees
Haryana, Rajasthan________________ 108__________
NIHFW, New Delhi
NICD, Delhi__________ Gujarat, Delhi____________________ 106__________
NIE, Chennai__________ Orissa, Pondicherry________________ 146
BJ Medical College, Pune Goa, Gujarat_____________________ 53___________
GMC, Nagpur_________ Chhattisgarh_____________________ 69__________
West Bengal, Manipur, Meghayala, 167
ADH&PH, Kolkata
Tripura_________________________
Haryana, Rajasthan, Chandigarh______ 115
PGI, Chandigarh
Total___________________________ 764
Quality control of training is an essential component of training strategy. In view of this it would
be necessary to conduct an evaluation as proposed in the PIP. This will be compared with similar
surveys during mid-term and end-line evaluation of the training activities. Faculty from Teacher
training centers (BHU, Varanasi; PGI, Chandigarh; AIIMS, Delhi and St. Johns Medical College,
Bangalore) and IndiaClen have been identified to conduct this evaluation as per plan given below:
States/UTs covered_________
Phase-H
Phase-I
NE Region
Teacher Training Centre, Mizoram
BHU, Varanasi________
Haryana &
Teacher Training Centre, Uttaranchal
PGI Chandigarh_______ Himachal Pradesh Chandigarh_________
Gujarat
Teacher Training Centre, Maharashtra
Rajasthan & Delhi
AIIMS______________ Madhya Pradesh
Goa
Karnataka
Teacher Training Centre,
Chhattisgarh
Andhra Pradesh
St. Johns, Bangalore
Pondicherry________
Kerala & Tamil West Bengal & Orissa
India Clen Group
Nadu
58
Organization
Phase-III
Uttar Pradesh
J&K
Punjab
UTs
Bihar
Jharkhand
First meeting of the Working group on evaluation of training was held on 12.12.05 at
NICD. It was attended by faculty from BHU, Varanasi, ADMS & Indiaclen. It was
decided that the survey instrument will be prepared by IndiaClen & pre-tested by them
after approval. This has been sent & comments from other members are awaited. Pilot
testing of the instrument will be completed by May 06 & final report is expected by July
06.
States are organizing other training programmes for medical Officers, Lab technicians
and Health Workers. Training of Accountants in Financial Management and Training of
Data Entry Operators in Application Software is also organized at the State level.
2.4 Procurement of Goods
M/s. Hospital Services Consultancy Corporation (HSCC) was appointed as Procurement
Consultant. During the year 2005-06, centralized procurement of major laboratory
equipment, computers and accessories and other office equipment was initiated. Current
status is as follows :
Letter of Award issued for Binocular Microscopes. Supply under process.
Evaluation of bids for other Lab. Equipment has been completed. Approval of
Integrated Purchase Committee (IPC) being sought.
Invitation for Bids for Diagnostic Kits being initiated
Evaluation of bids for Office equipment has been completed. Approval of IPC
being sought.
Computer Hardware:
a) To ensure that data collected in prescribed formats are compiled and analyzed at
the District level, 215 PCs with accessories were procured through National
Shopping procedures (DGS&D Rate Contract)
b) Centralized procurement of Computers and System Software for Phase I and II. Bids
were opened on 16.2.2006. Evaluation of bids has been completed. Approval of IPC
being sought.
<0 Servers would be procured after selection of software development agency.
2
2.5 Development of Software for Disease Surveillance
Preliminary software has been developed in-house for data entry and basic
analysis.
• In response to an advertisement published in leading national newspapers and UNDB
journal for selection of agency for software development and related services, 22 vendors
submitted Expression of Interest.
• A committee was constituted by the Ministry of Health & FW to shortlist 6 most
qualified bidders who were issued 'Request for Proposals’
• Detailed proposals have been received from following 4 short-listed bidders : IBM, Tata
Consultancy Services, Wipro and ECIL
Technical evaluation for the proposals has been completed and report submitted to the
World Bank for clearance.
2.6 Baseline Study on Public Health Laboratories
•
“Expression of Interest” was sought for conducting Baseline Study on Public Health
Laboratories and conducting Baseline External Quality Assurance System.
24
organizations had expressed interest. Six agencies were shortlisted. After seeking
clearance of the World Bank, RFP was issued to the six agencies. Proposals have been
received on 21st March 2006 and evaluation of the proposals has been initiated. Report
would be submitted by April 2006.
59
2.7 External Quality Assurance System :
There is limited availability of institutions who have capacity and/or experience of
conducting EQAS of laboratory services. It was decided to engage NICD, Delhi, NIV,
Pune, NICED, Kolkata and CMC, Vellore to share the responsibility. CMC Vellore was
given the responsibility to work out detailed proposal. This has been submitted and being
examined.
2.8 Monitoring of the Pro ject through Regional Coordinators
“Expression of Interest” was sought for Monitoring of Project through six Regional
Coordinators to be posted at Chandigarh, Bhopal, Bangalore, Gandhinagar, Kolkata and
Guwahati. 22 organisations had expressed interest. Six agencies were short-listed. After
seeking clearance of the World Bank, RFP was issued to the six agencies. Proposals
have been received on 21st March 2006 and evaluation of the proposals has been initiated.
Report would be submitted by April 2006.
2.9 Participation of Private Sector and Medical Colleges in IDSP
A Workshop was organized in April 2005 in Bangalore to discuss strategies for
involvement of private sector. A task force was constituted to develop scheme for
involvement of private sector in disease surveillance. A scheme including MOU was
prepared and forwarded to Indian Medical Association and Indian Academy of Pediatrics,
who have agreed to facilitate participation in IDSP. Four Orientation Workshops of key
members of these associations were planned of which two have been organized in Delhi
and at Thiruvanthapuram. Third workshop is being organized in Mumbai on 16lh April
2006. Scheme for participation of medical colleges has been prepared and forwarded to
the States and other stakeholders.
2.10 NCD Risk Factor Surveillance
The Working Group was constituted for development of protocol for NCD Risk factor
Surveillance. After several meetings, Study design and Sampling has been worked out.
Questionnaire to be used during the surveys has been finalized and being pre-tested.
Terms of reference for National Nodal Agency, Regional and State level Institutions have
been forwarded to the World Bank for clearance. Surveys would be undertaken after
awarding the contract.
2.11 Satellite Communication :
EDUSAT, a dedicated educational satellite launched by ISRO is being utilized to set up
communication and information network throughout the country. Central studio at
National Institute of Communicable Diseases with a sub-hub in Nirman Bhawan and 800
Satellite Interactive Terminals (SITs) located throughout the country would be set up
connecting all the State and Districts Units, Medical Colleges and premier state and
national public health institutions. Proposal has been submitted to the World Bank for
clearance.
This network will be utilized for distance training programmes,
teleconferencing and data transmission. Funds have been sanctioned from IDSP Budget
for 2005-06 to ISRO to cover 400 SITs by June 06. Remaining 400 SITs would be
covered during 2006-07 and covered by December 2006. Satellite Linkage would be
formally launched on 29th March 2006.
60
2.12 Information, Education & Communication
2.12.1 Guidelines, Operations Manuals and Reporting Formats
j
For an effective surveillance system, case definitions, operational procedures, reporting
formats etc. have been standardized by publishing and disseminating following formats :
• Operations Manual for District Surveillance Units
• Operations Manual for Medical Officers and Private Practitioners
• Operations Manual for Health Workers
• Laboratory Manual on Disease Surveillance
• Training Manual for District Surveillance Teams (Rapid Response Teams)
• Manual on Financial Management
• Standard Reporting Formats and Guidelines for their use
• Guidelines on Utilization of grant-in-aid
• Brochure/Executive Summary on Integrated Diseases Surveillance Project
• National Project Implementation Plan
A manual on Laboratory Techniques has also been developed by National Institute of
Communicable Diseases and would be used in the Project. Separate Manuals for Lab
Technicians posted at PHCs/CHCs and Manual on Bio-safety have been drafted and
would be published and disseminated.
2.12.2. Medical Agency
“Expression of Interest” was sought for selecting Media Agency at the central level. 18
organizations had expressed interest. EOI are being assessed and short-listing would be
completed by 15th April 2006.
2.12.3. Alternate approaches of communication
A proposal to capture information through alternate means of communication has been
prepared to capture information regarding focal out-breaks in the country through
scanning of newspapers and tele-news and by supporting Toll Free telephone services.
Details are given at Annexure 4,
2.13 PIP from Phase-II States
State PDFs have been received from all Phase-II States/UTs (Haryana, Goa, Gujarat,
Chhattisgarh, Rajasthan, Nagaland, West Bengal, Manipur, Orissa, Tripura, Pondicherry,
Meghalaya, Chandigarh and Delhi). MOU is awaited from Meghalaya. First instalment
of GIA has been released to the states, who have submitted MOUs. Orientation
workshops have been organized by Gujarat, Haryana, Chhattisgarh.
A Workshop was organized in October 2005 to orient Phase-DI states about preparation
of State PIP. It is expected to get PIPs from remaining states early during the year 200607.
2.14 Prevention & Control of Avian Influenza
Following the outbreak of Avian Influenza in chickens in Maharashtra and Gujarat, two
meetings were held with the officials from the World Bank. A draft Project
Implementation Plan on Surveillance Prevention and Control of Avian Influenza in India.
61
October, 2006
Report of the Working Group on
Public Health Services
(including Water & Sanitation)
for the Eleventh Five-Year Plan
(2007-2012)
Ministry of Health & Family Welfare
Nirman Bhawan, New Delhi -110011
INTRODUCTION
A Working Group was set up by the Planning Commission on Public Health
Services (including Water and Sanitation) for the Eleventh Five Year Plan with the
following Terms of Reference:
(i)
To review existing scenario of Public Health Services (including Water &
Sanitation) in urban and rural areas considering regional & inter district
disparities and with a view to provide universal access to equitable,
affordable and quality health care which is accountable at the same
time responsive to the needs of the people and also achieve goals set
under the National Health Policy and the Millennium Development
Goals.
/a)
To review the goals, objectives, strategies and expected outcomes of
the National Rural Health Mission by the end of the eleventh five year
period (2012) at all levels.
(Hi)
To review the implementation of major health and family welfare
programmes, functioning of infrastructure and manpower in rural and
urban areas, and suggest measures for rationalizing/restructuring the
infrastructure, strategies for improving efficiency and for the delivery of
services with a special focus on women & children.
(iv)
To review the challenges of the immediate future such as aging
population increased disease burden on account of new infections
and non-communicable diseases that have the potential to
impoverish the poor.
(v)
To review the mechanism for screening and referral of patients, so that
they receive appropriate care at all levels.
(vi)
To review disease control programmes and disease surveillance
mechanism in the country, its capability to provide up-to-date
information for effective timely response to prevent/limit disease out
breaks and to provide effective relief measures.
(vii)
Identify year-wise quantifiable goals and specific road map of the
NRHM and also suggest method of concurrent evaluation of NRHM.
(viii)
To suggest modification in policies, priorities and programmes during
] 1th Plan period in relation to:
(a) Priority areas of research to investigate alternative strategies;
(b) Mid-course correction of ongoing activities;
(c) New initiatives;
1
(d) Strategies to improve quality and coverage of services at
affordable cost, to cope with existing, reemerging and new
challenges in communicable diseases, emerging problems of noncommunicable diseases due to increasing longevity, life style
changes and environmental degradation;
(e) Provide all these services through NRHM and secondary health
care system in an integrated fashion;
(f) Improve disease surveillance, HMIS, effective timely response.
(ix)
To indicate manpower requirement and financial outlays required for
implementation of these programmes during the 11th Plan period;
M
To deliberate and give recommendations on any other matter
relevant to the topic.
The Composition of the Working Group is at Annexure-I. The meeting of
the Working Group was held on 17 August 2006 and the Report is based on the
suggestions obtained from Members.
The Terms of Reference (TOR) assigned to the Working Group is wide
ranging as it intends to cover not merely the health sector but also services
relating to the determinants of health including water and sanitation. As some of
these terms are inter-related, the TORs have been merged to facilitate focused
analysis and recommendations. In this regard, the TOR at (ii) and (vii) relating to
the National Rural Health Mission have been deliberated at one place.
In
respect of certain other terms of reference, while the salient issues have been
discussed, the detailed status including the framework required for the 11th Plan
may be referred to in the reports of the corresponding Working Groups. Specific
mention of TOR (iii) and TOR (vi) are relevant in this context. In the case of TOR
(iii), there is a separate Working Group which has delved into in great detail
about the health of women and children, while in the case of TOR (vi), the
Working Group on Communicable and Non-communicable Diseases have
reviewed the entire gamut of Disease Control Programmes including surveillance
and the details of the action plan proposed for the 11th Five Year Plan is
contained in that report.
2
The Working Group hod the benefit of the recommendations made in the
Mid-Term Appraisal of the Tenth Five Year Plan by the Planning Commission, the
Report of the National Commission on Macro Economics on Health and the
Framework for Implementation of the NRHM. Additionally, the reports generated
by the Task Forces while formulating and implementing the Rural Health Mission
have also been available to this Group.
The Report attempts to place in greater focus the lessons learnt from the
current experience and draw up an action plan for improving the availability,
accountability and affordability of public health services including water and
sanitation.
3
Terms of Reference-1
(i)
To review existing scenario of Public Health Services (including Water &
Sanitation) in urban and rural areas considering regional and inter district
disparities and with a view to provide universal access to equitable, affordable
and quality health care which is accountable at the same time responsive to the
needs of the people and also achieve goals set under the National Health Policy
and the Millennium Development Goals.
Public Health services play a critical role in promoting, restoring or
maintaining the health status of a population whether they do so effectively
depends on which services are provided and how they are organized. These
services basically take the form of healthcare infrastructure, manpower facilities
relating to supply of clean drinking water, sanitation and hygiene besides a host
of other inter-related activities. In terms of physical infrastructure, there exists a
network of 1,46,026 sub-centres, 23,236 PHCs and 3346 CHCs with the sub-centres
catering to a population of 1 per 5000 (3000 in the case of tribal areas), 1 per
30,000 population in respect of PHCs (20,000 in tribal and desert areas) and 1 per
1,20,000 in CHCs in general
in tribal / desert areas ).
areas ( as against 1 per 80,000 population
Availability of medical manpower for the country
as a whole shows that for every
1,00,000
population there are 70
doctors. Across rural areas, the public health manpower include 28,930 nurse
mid-wives, 1,33,194 ANMs, 61,907 male MPWs, 17,708
58,752
paramedical
staff
in
addition
pharmacists and
to
non
technical staff.
With this infrastructure, significant progress has been achieved in the
planning era as evident from the trends in the health sector as given below:
4
Table 1 : INDIA-SELECT HEALTH INDICATORS
S.No.
1
2.
3.
4.
5.
6.
7.
8.
______ Parameter
Crude birth rate
(Per 1000 population)
Crude death rate
(Per 1000
1951
40.8
1981
33.9
1991
29.5
Current level
24.8(2003)
25.1
12.5
9.8
8.0 (2003)
Total fertility rate(TFR)
(Per Woman)__________
Maternal mortality ratio
(MMR)
(Per 100,00 live births)
Infant mortality rate (IMR)
(Per 1000 live births)_____
Child (0-4) mortality rate
(Per 1000 children)______
Couple protection rate
(per cent)*____________
Life Expectancy at birth
6.0
4.5
3.6
3.0 (2001)
NA
NA
437
(1992-93)
407(1998)
146
(1951-61)
57.3
(1972)
10.4
(1971)
110
80
60(2003)
41.2
26.5
17.8(2002)
22.8
44.1
48.2(1998-99)
37.2
54.1
63.9(2001-08)
66.9(2001-06)
36.2
54.7
59.7
(1991-95)
60.9
(1991-95)
8.1 Male
8.2 Female
Note:
* National Family Health Survey
NA: Not Available
Source: Economic Survey 2005-06
The health outcomes for India as a whole disaggregated by major States
is at Annexure-ll.
However, despite a massive public health infrastructure that has been
created over the plans, the determinants of health have not been assigned the
desired focus limiting the success that could have been otherwise achieved.
Alongside another discernible phenomenon is that the public health care
facilities have been accessed and utilized differently in the rural and urban areas
for purposes of outpatient and inpatient care.
According to the NSSO 60th
Round, public facilities for outpatient care have been accessed by 22% in the
rural areas and 19% in the urban areas. It may be pertinent to note that while %
of treated ailments receiving non-hospitalized treatment from government
sources registered a slight increase from 19 to 22 during 1995-96 to 2004, it
5
revealed a marginal decline in urban areas from 20 to 19 during the same
period. States showing an increase in this share were Orissa, Kerala, Karnataka
and Rajasthan in respect of rural areas and Orissa, Punjab and Rajasthan in
respect of urban areas. The States of Bihar and Gujarat showed a decline in the
share of public institutions in treatment of non-hospitalized ailments in the rural
and urban areas while a significant decline in the share of public institutions in
treating ailments can be seen in the urban areas of Kerala, Maharashtra and
Tamil Nadu.
However between 1986-97 and 2004, outpatient care in urban
areas from government services have registered a steep fall from 24% to 19%. A
state-wise picture capturing the variations across States and during the last 3
rounds of survey by NSSO over the period 1986-87 to 2004 in respect of both rural
and urban areas for outpatient care is given in Annexure III.
As regards hospitalized treatment the picture is even more discouraging
(captured in the 60th Round). The private sector has been the main provider of
inpatient healthcare both in the rural and urban areas and the roles between
the private and public sector seem to have reversed as evident from the table
below:Table 2 : Per 1000 distribution of cases of hospitalized treatment by type of
hospital during 2004, 1995-96 and 1986-87
Rural
Type of
Hospital
Govt.
Non
Govt.
Urban
2004
(60th)
1995-96
(52nd)
1986-87
(42nd)
2004
(60th)
1995-96
(52nd)
1986-87
(42nd)
417
583
438
562
597
403
382
618
431
569
603
397
Source: NSSO 60th Round-Report 507 on Morbidity, Healthcare and condition of
aged.
6
Reliance on the public sector tor hospitalized treatment varied largely
between States. The state-wise variations as captured by the 60th Round is at
Annexure-IV.
According to the NSSO 60th Round, the proportion of hospitalized
treatments received from public sector hospitals varied from 144 in Bihar to 913 in
J&K in the rural areas. Besides J&K, 3 other States namely Orissa, West Bengal
and Himachal Pradesh reported relatively high proportion of cases of
hospitalized treatment from public institutions. The States of Andhra Pradesh,
Bihar, Haryana, Maharashtra and Uttar Pradesh showed a high degree of
reliance on private sector hospitals. 62% of beds were in government hospitals
but the performance in the public hospitals in terms of proportion of hospitalized
cases treated falls short of the beds in public institutions.
More than one third of all deaths in India are in the under 15 age group,
most of them infants. The regional variation is best highlighted with States like
Bihar, Madhya Pradesh, Uttar Pradesh, and Rajasthan reporting more than 40%
of all deaths in the under 15 age group as compared to only 6 percent such
deaths in Kerala, as recently as 1998. Similarly, more than two thirds die before
reaching age 60 in the first category of States, compared to only one third in the
case of Kerala and half in the case of Tamil Nadu, Maharashtra and Himachal
Pradesh. If this data is analyzed further for gender and social groups, clearly
women from poorer households suffer the most. This is well documented in the
surveys of NFHS and NSS.
Access to rural and urban water supply, drainage and sanitation equally
contribute to good health. Though efforts to address these determinants have
been made in the past, a large segment of the population have lived without
them. Water is a state subject akin to health and the schemes for providing
drinking water facilities are implemented by the States. The efforts of the Central
Government are in the nature of financial and technical assistance and merely
supplement the initiatives of the State Governments. As of April, 2005, 96.1% or
7
rural habitations were fully covered and 3.6% were partially covered leaving 0.3%
not covered with drinking water facilities.
State-wise data indicate that while in most States, habitations in rural
areas have been fully covered, habitations not covered are as high as 2300 in
Rajasthan, 803 in Punjab, 660 in J&K and 327 in Maharashtra. A habitation survey
conducted in 2003 indicate large incidences of slippage from fully covered to
partially/not covered categories due to a number of factors such as: services
going dry, lowering of ground water level, systems outliving their lives and
increase in population resulting in lower per capita availability.
In terms of
absolute numbers, according to the Department of Drinking Water Supply, the
population under rural water supply programme during 2005-06 is 188.32 lakhs of
which SCs constituted 32.85 lakhs, STs 22.17 lakhs and general population 133.29
lakhs.
Sanitation is another factor decelerating Improvements in health status.
Data collected in Census 2001 quoted in the National Health Profile 2005
indicates the percentage of households by toilet availability and type of
drainage connectivity.
The state-wise scenario is at Annexure-V.
While
households having bathroom facility within the house is abysmally low in rural
areas and urban areas in the BIMARU States, NE, J&K and Orissa, the position in
respect of connectivity for waste water outlet is even more alarming.
While
closed drainage is available in the urban areas atleast in the developed States,
a large percentage of bathrooms across all States in the country have no
drainage system particularly in the rural areas. This percentage is as high as
73.88 in Orissa, 72.69 in Assam and 71.81 in Chhattisgarh. The non-availability of
toilets within the house in % terms is as high 71.94 in Bihar, 76.78 in Chhattisgarh
and 73.03 in Jharkhand. In urban areas, the % of households not having toilet is
marked in the case of Goa (15.26), Maharashtra (17.75), Chandigarh (17.83),
Delhi (19.58) and Tamil Nadu (14.84).
10595 P°6
VO-?
^7
The baseline survey data from the PIPs of States compiled from October,
2003 onwards gives the status of household sanitation coverage in terms of toilet
coverage and their economic status.
The state-wise sanitation coverage in habitations, anganwadi centres and
schools as reported in the State PIPs since 2003 are given in Annexures VI, VII and
VIII. The situation is further compounded on account of manual scavenging
prevalent particularly in rural areas. Lack of these basic amenities of sanitation
has posed a serious health hazard and the recent epidemics of chikunguniya
Absence of safe
and dengue can be traced to unhygienic living conditions.
drinking water combined with lack of proper sanitation have very often been
important factors contributing to ill health and morbidity levels in the country.
The public health system in a sense has also not met the principle of
equity in its delivery of healthcare services. This may be traced to a series of
factors ranging from lack of medical personnel, drugs and equipment,
inaccessible facilities or due to a poorly dysfunctional organization of the health
system even where in some cases inputs exist and financial support is adequate
and well-distributed. The National Health policy 2002 has highlighted the inequity
in access to and availing of services by the disadvantaged groups. Infact the
differentials in health status among socio-economic groups can be seen from
the table below:
Table 3: Differentials in Health status among Socio-economic Groups
5
%
Infant
Under
Mortallty/1000
Mortality/1000
Underweight
70
949
47
Scheduled Castes
83
119.3
53.5
Scheduled Tribes
84.2
126.6
55.9
Other Disadvantaged
76
103.1
473
Others
6L8
82.6
TTT
Indicator
India
Children
Social Inequity
Source: National Health Policy 2002.
9
Besides equity between different sections across the board, this has taken
a toll on women and gender sensitive interventions not given adequate focus.
The health status and burden of disease in different social groups as
documented in the NCMH Report compiled from NFHS-II, 1998-99 is at Annexure-
IX.
The key challenge continues to be the prevalence of high levels of
inequity in health conditions across and within States and different strata of
population.
The multi sectoral determinants of health largely explain the
variation in outcomes between different region/states. Malnourished children
are easily susceptible to diseases and die from them. The environment in which
we live particularly if it has no sanitation or poor sanitation provide a fertile
environment for transmission of intestinal infections. Growth in vehicular traffic
and primitive modes of cooking especially in rural areas give rise to a variety of
respiratory diseases.
Inadequacy and ineffective public health services combined with a clear
absence of convergence between different programmes and Departments
have promoted implementation of a variety of initiatives within and outside the
health sector without maximizing outcomes in a holistic and cost effective
manner. Community participation is also not always clearly visible in several of
our endeavour which is ubiquitous for the success of any intervention.
10
Terms of reference (ii) & (vii)
(H)
To review the goals, objectives, strategies and expected outcomes of the
National Rural Health Mission by the end of the eleventh five year period
(2012) at all levels.
(vii)
identify year-wise quantifiable goals and specific road map of the NRHM
and also suggest method of concurrent evaluation of NRHM.
The National Rural Health Mission (NRHM) has been launched with a view
to provide effective healthcare to rural population throughout the country with
special focus on 18 States, which have weak public health indicators and/or
weak infrastructure. These 18 special focus states include Arunachal Pradesh,
Assam, Bihar, Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu and Kashmir,
Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan,
Sikkim, Tripura, Uttaranchal and Uttar Pradesh. The Mission seeks to provide
universal access to equitable, affordable and quality health care which is
accountable at the same time responsive to the needs of the people, reduction
of child and maternal deaths as well as population stabilization, gender and
demographic balance. Besides it aims at revitalizing local health traditions,
mainstream
AYUSH
and
effectively
integrate
health
concerns
through
decentralized management at the district with determinants of health like
sanitation and hygiene, nutrition, safe drinking water, gender and social
concerns. In the process, the Mission would help achieve goals set under the
National Health Policy and the Millennium Development Goals as also address
inter and intra state disparities.
The NRHM, an architectural correction mechanism is envisaged to
operate in a mission mode for a seven year period from 2005-2012. The activities
to be undertaken alongwith its phasing and timeline over the mission period is
captured in the table below:
11
TIME LINE FOR NRHM ACTIVITIES
Activity
Phasing and time
line_____________
50% by 2007
100% by 2008
1
Fully trained Accredited Social Health
Activist
(ASHA)
for
every
1000
population/large isolated habitations.
2
Village Health and Sanitation Committee
constituted in over 6 lakh villages and
untied grants provided to them.
30% by 2007
100% by 2008
3
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
4
30,000 PHCs strengthened/established
with 3 Staff Nurses to provide service
guarantees as per IPHS.
30% by 2007
60% by 2009
100% by 2010
5
6500 CHCs strengthened/established with
7 Specialists and 9 Staff Nurses to provide
service guarantees as per IPHS.
30% by 2007
50% by 2009
100% by 2010
6
1800 Taluka/ Sub Divisional Hospitals
strengthened to provide quality health
services.
30% by 2007
100% by 2010
7
600 District Hospitals strengthened to
provide quality health services.
8
Rogi Kalyan Samitis/Hospital Development
Committees established in all CHCs/Sub
Divisional Hospitals/ District Hospitals._____
District Health Action Plan 2005-2012
prepared by each district of the country.
30% by 2007
60% by 2009
100% by 2010
50% by 2007
100% by 2009
9
10
11
Untied grants provided to each Village
Health and Sanitation Committee, Sub
Centre, PHC, CHC to promote local
health action._______________________
Annual maintenance grant provided to
every Sub Centre, PHC, CHC and one
time support to RKSs at Sub Divisional/
District Hospitals.
50% by 2007
100% by 2008
50% by 2007
100% by 2008
50% by 2007
100% by 2008
13
Systems of community monitoring put in
place.
50% by 2007
100% by 2008.
14
Procurement and logistics streamlined to
50% by 2007
12
ensure availability of drugs and medicines
at Sub Centres/PHCs/ CHCs.
100% by 2008.
15
SHCs/PHCs/CHCs/Sub Divisional Hospitals/ 30% by 2007
District Hospitals fully equipped to 50% by 2008
develop intra health sector convergence, 70% by 2009
coordination and service guarantees for 100% by 2010
family welfare, vector borne disease
programmes, TB, HOV/AIDS, etc.
16
District
Health
Plan
reflects
the
convergence with wider determinants of
health like drinking water, sanitation,
child
women’s
empowerment,
school
development,
adolescents,
education, female literacy, etc.
30% by 2007
60% by 2008
100% by 2009
17
Facility and household surveys carried out
in each and every district of the country.
50% by 2007
100% by 2008
18
Annual State and District specific Public
Report on Health published
19
Institution-wise
assessment
performance against assured
guarantees carried out.
30% by 2008
60% by 2009
100% by 2010.
30% by 2008
60% by 2009
100% by 2010.
20
Mobile Medical Units provided to each
district of the country.
of
service
30% by 2007
60% by 2008
100% by 2009.
The outcomes under the different activities will be monitored through a
mix of several measures that will include annual facility surveys, external
assessments, calling for quarterly and annual progress reports.
A review of the progress achieved as of October, 2006 under the Mission
reveals the following:
Institutional arrangements set up
1.
•
State Health Missions constituted in all States/UTs.
•
State launch along with orientation of DMs/CMOs completed in 15 focus
states.
•
Merger of Departments of Health & Family Welfare completed in all states
except Uttar Pradesh and Goa.
•
MoU finalised with 28 States.
13
ASHA
2.
•
Under the approved Framework for Implementation, ASHAs are proposed
in ME states and hilly/tribal districts of all other states also.
•
During 2005-06, 1.21 lakh ASHAs were selected and during 2006-07 (till
date) 1.08 lakh ASHAs have been selected in various states.
•
Till date 1.17 lakh ASHA have been trained in the states.
•
Detailed guidelines for the mentoring of ASHAs in the states and the
associated generic funding have been disseminated to the states
3.
Infrastructure
•
Total amount: of Rs. 205.87 crore released during 2005-06 and Rs. 46.82
crores during 2006-07 as Untied funds for local action to all sub-centres in
the country.
•
Indian Public Health Standards have been finalized for CHCs. Similar
standards are in final stages of preparation for Sub Centres, PHCs and
District Hospitals.
•
1680 CHCs have been identified by the states for upgradation to IPHS in
the first phase. Total amount of Rs. 370 crores was released during 2005-06
and Rs. 326.40 during FY 2006-07 till date for this purpose.
•
Facility Survey has been completed in 902 CHCs across the country.
•
6355 Rogi Kalyan Samitis have been set up at various.
•
The Mobility support being given for outreach programmes in the
underserved areas.
108 Integrated District Health Action Plans have been prepared in various
states. These plans are sector wide in import and address all aspects of
health
including the collateral health
determinants like nutrition,
sanitation, drinking water etc.
14
Human Resource Development
4.
•
Recommendation of the Task Group on Medical Education has been
finalized and are in final stages of consideration by the Ministry.
•
The Task Group on Identification, training and accreditation of RMPs in in
the final stages of deliberations.
•
Accounts personnel are being positioned in the PHCs to strengthen the
accounting of funds in view of the substantially larger number of
transactions at that level.
•
12738 Doctors, ANMs and other paramedics have been appointed on
contract by States to fill in critical gaps.
•
Block pooling of doctors has been started in states so as to ensure that
there is at least one functional health facility in each of the block. The
other health facilities in the territorial are being serviced through outreach
visits.
•
700 professionals (CA/MBA) appointed for EAG States in the Program
Management Units (PMU) to support NRHM. Similar management support
is being planned at the level of the Block also.
Training
5.
•
National Health Resource Centre at Central level finalized.
•
State level Health System Resource Centre for North East States set up at
Guwahati.
•
Additional training initiatives undertaken including :
o
Upgradation of State Training Institutes/ANMS Colleges
o
Integrated Skill Development Training ANMS/ LHV/MOs.
o
Skilled Birth Attendants Training MO/ANMs
o
Training on Emergency Obstetrics care for MOs.
o
Training on No Scalpel Vasectomy (NSV) for MOs.
o
Professional Development Programme for CM Os.
o
Specialised skill development programme for MOs.
o
Training program for Consultants of Program Management Units
15
New Programs & Innovations
6.
•
RCH II launched and under implementation
•
Expanded coverage under Janani Suraksha Yojana approved by the
Mission Steering Group.
•
Sterilization compensation scheme launched by GOI
•
Integrated Management of Neonatal and Childhood Illnesses (IMNCI)
started this year in 16 States namely MP, WB, Jharkhand, UP, Haryana,
Maharashtra, Delhi, Mizoram, J&K, Uttaranchal, Bihar, A&N island, Assam,
Andhra Pradesh, Chhattisgarh & Karnataka .
•
With the help of Neonatology Forum completed training on Newborn
Care in 140 districts in the country.
•
Integrated Disease Surveillance Project operationalized.
•
Legal changes brought about to allow the ANMs to dispense medication
and MBBS doctors to administer anesthesia.
•
Short course for anesthesia being planned.
•
Risk Pooling and Health Insurance models compiled and shared with the
states.
•
Empowered Procurement Wing set up in the Ministry
•
Single Purchase Committee set up under DGHS
•
Involvement of HLL for supply of drugs to EAG/ North East States being
finalized.
7.
Immunization
•
Accelerated Routine Immunization (Rl) taken up in all EAG states
•
Catch up rounds taken up in Bihar, Jharkhand, Orissa and Assam and
other states.
•
JE vaccination campaign covered 93.8 lakh children.
16
Partnership with Non Government Stakeholders
8.
•
225 Mother NGOs appointed for 331 districts in 2005-06.
•
Providing services, RCH out reach services. Ambulance Services, Mobile
Medical Units, Mentoring of ASHA, Management of Health facilities (as in
Gujarat Tamil Nadu etc) , Involvement of Medical colleges. Training
programmes, ICCI, Partnership in polio/ immunization programmes etc.
IEC
9.
•
IEC Multi-media campaign
on health issues including immunization,
Iodized Salt, Save the Girl Child
•
NRHM New letter
•
Health Melas organized in different States.
•
Information booklets disseminated.
•
Behaviour change workshops being organized for key stakeholders
including state IEC representatives.
By the end of the Mission period i.e. 2007-2012 which coincides with the
final year of the Eleventh Plan, the expected outcomes to be achieved in
quantitative terms are:
•
IMR to be reduced to 30/1000 live births by 2012.
•
Maternal Mortality to be reduced to 100/100,000 live births by 2012.
•
TFR to be reduced to 2.1 by 2012.
•
Malaria Mortality Reduction Rate - 50% up to 2010, additional 10% by 2012.
•
Kala Azar Mortality Reduction Rate - 100% by 2010 and sustaining elimination
until 2012.
17
•
Filaria/Microfilaria Reduction Rate - 70% by 2010, 80% by 2012 and elimination
by 2015.
•
Dengue Mortality Reduction Rate - 50% by 2010 and sustaining at that level
until 2012.
•
Cataract operations-increasing to 46 lakhs until 2012.
•
Leprosy Prevalence Rate -reduce from 1.8 per 10,000 in 2005 to less that 1 per
10,000 thereafter.
•
Tuberculosis DOTS series - maintain 85% cure rate through entire Mission Period
and also sustain planned case detection rate.
•
Upgrading all Community Health Centers to Indian Public Health Standards.
•
Increase utilization of First Referral units from bed occupancy by referred
cases of less than 20% to over 75%.
•
Engaging 4,00,000 female Accredited Social Health Activists (ASHAs).
Besides the above, the Mission will mobilize the health workers, non
government organizations and the community at large in facilitating access to
health services, improved outreach services to the underserved areas, its
effective utilization and ensuring proper accountability to the citizens.
The
emphasis will not be on health services per se but also on the major determinants
of good health namely water supply, sanitation etc. The Mission will also steer
towards promotion of inter-sectoral convergence and forging of a meaningful
partnership by the centre with the states and local bodies.
18
Term of Reference - m
To review the implementation of major health and family welfare
(Hi)
programmes, functioning of infrastructure and manpower in rural and urban
areas, and suggest measures for rationalizing/restructuring the infrastructure,
strategies for improving efficiency and for the delivery of services with a
special focus on women & children.
The major programmes under Health are the National Disease Control
Programmes that have been designed and are being implemented to arrest the
spread of communicable and non-communicable diseases. The individual
disease control programmes have been reviewed in detail by the Working
Group on Communicable and Non-Communicable Diseases.
The salient
measures and strategies suggested by the Working Group in respect of the major
programmes have been highlighted in this report under Term of Reference (vi)
which relate specifically to Disease Control Programmes and Surveillance
mechanisms.
Under Family Welfare, the major schemes relate to Reproductive and Child
Health,
Infrastructure
Maintenance,
IEC
activities
and
Distribution
Contraceptives, Immunization, Area Projects and Research Institutions.
of
These
schemes have been suitably modified in 2005-06 and brought under the overall
umbrella of the National Rural Health Mission.
The major constraints in the implementation of programmes and schemes
particularly under Family Welfare have been in the realm of physical
infrastructure, manpower and other support facilities for an effective healthcare
delivery system. Infrastructure where available had not been fully operational
due to critical gaps in availability of doctors, para-medics, drugs, diagnostic
facilities etc. Non-availability of specialists was another critical factor. There has
virtually been very little emergency obstetric care available and health
programmes and schemes by and large operating as vertical programmes.
19
The
NRHM
launched
in
April,
2005
has
drawn
up
a
detailed
implementation framework to ensure that infrastructure created is fully functional
backed by adequate manpower and other resources.
In so far as Reproductive Child Health is concerned significant progress
has been achieved under RCH. The first phase of the Reproductive Child Health
Programme was launched in 1997 by integrating all ongoing fertility regulation
and maternal and child health schemes of the Ministry under a single umbrella
adopting a holistic target free approach. The first phase of RCH was assessed
and taking note of the shortcomings, RCH Phase-ll is under implementation since
2005. A review of the RCH Phase-1 and the achievements made under RCH-II
have been made in great detail in the Report of the Working Group on Health of
Women and Children.
The sector level policies governing RCH-II design and implementation as
contained in the Working Group Report on Health of Women and Children is
given below:
Sector level policies governing RCH-II design and implementation
•
Bring about inter-sectoral collaboration through networking at the highest
levels and then percolating to the different levels.
•
To include public health as a specialization into the medical education
curriculum in order to bring out trained public health managers to
manage the public health and bringing in public health as a function.
•
To revitalize the human resources policy such as district cadres of MOs
and block cadres of ANMs and also address the career movement.
posting and training issues.
•
Open up primary health care to groups of professionals/ individuals willing
to take on such service provision functions especially at the primary levels
accompanied by appropriate governance mechanisms.
20
•
Activating voluntary level societies/ community level workers for bringing
in additional funds into the sector (ZSS, RKS+JSK, ASHA)
.
Address adolescent health as an important issue and develop packages
for activating this aspect.
.
Integrate with the ongoing National AIDS Control Programme (NACP) and
establish linkages with HIV prevention programmes.
•
Develop separate plans for dealing with the problems of vulnerable
groups including a tribal action plan and an action plan for the urban
poor.
A number of initiatives have been suggested by that Working Group for
improving service delivery which include Public Private Partnerships and systemic
approach for meeting the human resource challenges.
While efforts to
strengthen and optimize existing public facilities with more investment and better
management should receive priority, collaborating with the private sector will still
be required for meeting the growing demand and utilizing the expertise
available with them. Some of the specific suggestions in respect of these have
been extracted from the Working Group Report and highlighted in this section.
To expand the network of fully equipped facilities the following have been
suggested:
.
Ensure district hospital is fully equipped for the FRU services;
•
Strengthen midwifery skills of existing ANMs through their attachment to
district hospital; add more facilities for skill-development training after they
are fully equipped for FRU services,
.
Adopt multiskillng as the main strategy for strengthening service delivery,
both for doctors as well as the paramedical staff.
21
Given the crucial role nursing/paramedical manpower play in the delivery of
healthcare services the Working Group has suggested:
•
A dedicated Nursing and Paramedical Manpower Division/Unit should be
established at the National and State levels.
•
All medical colleges should be mandated to establish a College of
Nursing offering courses in B.Sc Nursing, M. Sc. Nursing and Post-Basic
Diploma courses in speciality nursing areas.
•
All District Hospitals should be mandated to establish a school of nursing
offering ANM and Diploma in General Nursing and Midwifery.
•
Smaller hospitals in public sector having at least 30 OBGs beds should be
encouraged to start ANM training
•
Private sector hospitals having at least 30 OBGs beds should also be
allowed to start ANM training programme and the concerned State
Government should allow selected public sector rural facilities for their
field training.
Other major recommendations made by the Working Group include:
Revision in the allocation ot seats under PG Medical course to provide for
more seats in the specialities required in rural areas.
•
Treat external assistance with zero debt liability as an additionality to the
domestic budget.
•
Need to develop a robust MIS by triangulating data and information from
routine
reporting
systems,
external
programme
evaluations
and
community based assessment of programme implementation.
22
Term of Reference - IV
(iv)
To review the challenges of the immediate future such as aging
population increased disease burden on account of new infections and
non-communicable diseases that have the potential to impoverish the
poor.
Care of the Elderly: Proposed Geriatric Programme
According to the 2001 Census, there are 76.6 million people at or over the
age ot sixty in India, constituting about 7.7% of the total population. Life
expectancy has increased from around 59 years in the 1970s to 63 years
currently, and is expected to cross 70 years by the year 2020. The proportion of
elderly in India is set to rise dramatically in the next few decades.
One major area of concern in the above context, is the Health of the
elderly, which requires a comprehensive care of providing preventive, curative &
rehabilitative services. Unlike the developed countries, India does not have a
well-structured Geriatric Health service, thus leading to a relatively ad hoc
system of health care delivery for the elderly. In this scenario, there is a need for
a specialized geriatric health service, which recognizes the elderly as being a
vulnerable population. The service must educate, to develop and maintain
lifestyles, which are healthy. It must provide a counseling and medical care
facility to look after the needs of the sick elderly, and an emergency facility to
reach those in acute need and transport them to a hospital. This should include
acute care, long term care & community based rehabilitation
23
In the long run, the aim of the program is to provide quality services
closest to the homes of the elderly; to keep them functional and to make them
return to the community as early as possible after illness. Hence easy
accessibility, continuity and good quality of care are essential components of a
Geriatric Health Care System.
To improve the access to promotive, preventive, curative and emergency
health care among elderly persons a range of services to be provided has been
envisaged at three levels under the proposed geriatric programme
Level One:
A Home Health service, which will comprise of a visiting component
intended as an early warning system to detect health problems, and as a source
of psychological support.
Level Two:
A community based health centre for the elderly providing a base
for educational and preventive activity and an out patient medical service. This
would be the base for the home health service, and for the program in general.
Level Three: An improved hospital-based support service with focused health
care needs at the institute.
The Working Group on Communicable and Non-Communicable Diseases
has looked at the care of the elderly and proposed a roadmap for the 11th Five
Year Plan. The Report has recommended the setting up of two national institutes
of ageing one in Delhi and one in Chennai supported by regional centres to be
spread across 19 States in the first instance.
The national program for health care of the elderly will be a centrally
funded program.
The eight regional centres will be identified under the control
of these two institutes. On an average, each regional centre will be involved in
implementing Geriatric Health Care in about 3 to 4 states. These will be at
Trivandrum, Bangalore, Hyderabad, Vellore, Kolkata, Mumbai, Jodhpur and
Guwahati. The existing geriatric services will be up graded in these Regional
centres.
24
In each state one teaching medical College / Tertiary level hospital will be
selected to develop the Geriatric Unit which will include the Outpatient services,
Acute care , subacute Care and Long Term Care units. In total 35 such centres
will be supported in this programme.
These identified Medical Colleges will be further linked to 5 districts each in
their vicinity. In total 175 District Hospitals will be strengthened for providing
geriatric care. The Medical colleges will also be responsible for the geriatric care
services in the identified urban centres in the adjacent areas.
The health professionals will be trained at the Medical colleges and
regional centres to fill in the gap in manpower. They will then be sent to the
district level centres for delivery of Geriatric Health Care. The manner in which
these institutes in the Centre and States will function has also been spelt out in
that Report.
The public health system is already stretched by the co-existence of
communicable and infectious diseases and alongside an emerging epidemic of
non-communicable diseases.
While the national programmes to control
communicable diseases are meeting with success, emergence of new infections
and non-communicable diseases particularly diabetes, life-style diseases and
CVDs need to be effectively prevented as curative care costs fro these diseases
are very high. Preventive strategies will vary according to causal factors. The
plan of action proposed for controlling communicable diseases and measures
for non-communicable diseases has been dealt with comprehensively in the
Report of the Working Group on Communicable and Non-Communicable
Diseases. The Report also includes a section on operational research that is
required in the areas of communicable and non-communicable diseases in the
future.
25
Term of Reference - v
To review the mechanism for screening and referral of patients, so that
(v)
they receive appropriate care at all levels.
The principal challenge in the health sector today is the building of a
sustainable healthcare delivery system whereby all citizens including the rural
poor and the disadvantaged sections of the society would have access to
affordable and appropriate quality healthcare at all levels. In the existing system
fragmented strategies and lack of manpower and other resources have made
the health system unaccountable and inadequately equipped to meet the
health requirements particularly in the rural areas where there is massive public
health infrastructure. This physical infrastructure however is not always supported
by availability of doctors/para-medics, drugs, equipments, diagnostic services
etc.
Lack of facilities particularly for emergency obstetric care and non
availability of specialists for anesthesia, obstetric care, pediatric care etc. have
either resulted in the needy move towards the private sector or not access
healthcare at all. Also the system was not suitably integrated resulting in limiting
the outcomes of health through implementation of different programmes and
schemes.
The National Rural Health Mission has as its basic objective effecting an
architectural correction to the existing healthcare delivery system and has drawn
up a plan of action at all levels of healthcare i.e. village, sub-centre, PHC, CHC,
district and state.
The plan visualized to operationalize this objective is
enumerated in the paragraphs that follow.
26
Village level
The Mission provides for a trained female community health worker ASHA- in each village in EAG states who is expected to work very closely
within the villages and could contribute directly in a number of health
related activities. ASHAs would reinforce community action for universal
immunization, safe delivery, newborn care, prevention of water-borne
and other communicable diseases, nutrition and sanitation, in close
coordination with ANMs/AWWs. This network of female link workers would
act as the nucleus for coalescing all forces to empower women in the
villages.
There would be a Health Day every month at the Anganwadi level in
which immunization, ante / post natal check ups and services related to
mother and child health care including nutrition would be provided.
One health Unit to be established in every village which would be owned
by the community and managed by the Village Health and Sanitation
Committee, with the help of ASHA/AWW/SHG group, etc.
At each Anganwadi there would be a room to serve as focal point for
health activities in the village.
Provision of a revolving fund at the village level to be managed by VHSC
for providing referral and transport facilities for emergency deliveries as
well as immediate financial needs for hospitalization.
Identify RMPs and upgrade their skills by specialized training to deliver
health care.
27
For those villages which are far away from the Sub-Centre, identification
of a TBA with requisite educational qualifications for training and
upgradation to the level of Skilled Birth Attendant to assist the ANM at the
Sub Centre. They are to be paid Rs. 50/- per institutional delivery assisted
by them at the Sub Centre.
Orientation of the members of the VHSC to equip them to provide
leadership as well as plan and monitor the health activities as the village
level.
Untied fund to be made available to VHSC for various health activities
including
IEC,
household
survey,
preparation
of
health
register,
organization of meetings at the village level etc.
Sub-Centre level
The Sub-Centres are currently provided on the population norm of 1 per 5000
population in general areas and 1 per 3000 population in tribal areas. Even by
1991 population norms, against a requirement of 1.34,108, if we ignore the
excess sub-centres in some of the states, there is a shortfall of 4822 sub-centres.
Going by the population of 2001, the requirement climbs to 1,58,702 and the
deficit increases to 21, 983. Of the existing sub-centres, only 63,800 are in
government buildings. If we further exclude those buildings which are currently
functioning from Panchayat and other voluntary society buildings, buildings need
to be constructed for as many as 59,226 of them. The vacancy position at the
Sub-Centres is equally discouraging. Against a requirement of one ANM (funded
by the GOI) and one MPW (funded by the states) positions of as many as 11,191
and 67,261 respectively are vacant.
The number of ANMs is proposed to be linked to the caseload and the
distance of village / habitations which comprise the sub-centre and not to
the population as population density is not uniform resulting in inadequate
availability of health services.
28
Two ANMs are to be provided for each sub-centre. These ANMs besides
fulfilling the laid down criteria will also be a resident of a village falling
under the jurisdiction of that sub-centre and not be transferred before
completion of 10 years.
Construction of sub-centres would be taken up in a phased manner over
the mission period.
To bring in greater community control, the sub-centres would be fully
brought under the Panchayati Raj framework.
Besides the usual recurring cost support to the sub-centres, they also
would be given an untied support of Rs. 10,000. The fund would be kept in
a joint account to be operated by the ANM and the local Surpunch.
The Sub-Centre building could also be utilized for dispensing OP services
by any health provider. Adequate provision of medicines would be made,
not only pertaining to RCH but also of other communicable diseases. The
availability of AYUSH drugs would also be ensured.
Two TBAs would be attached to every Sub-Centre without any financial
liability. These TBAs would be selected with a view to train them
subsequently to the level of SBA by further skill upgradation. They would
be paid Rs. 50/- on a case to case basis for an institutional delivery at the
Health Sub Centre.
PHC Level
The PHCs are currently provided on the population norm of 1 per 30,000
population in general areas and 1 per 20,000 population in tribal / desert areas.
Even by 1991 population norms, against a requirement of 22,349, if we ignore
29
the excess in some of the states, there is a shortfall of 1374 PHCs. Going by the
population of 2001, the requirement goes up to 26022 and the deficit increases to
4436. Of these PHCs, as many as 1693 do not have their own buildings. The
PHCs are expected to have two doctors. However, even if we work out the
requirements on the basis of one doctor alone, there are 880 vacancies which
clearly imply that many of the PHCs are without doctors.
The availability of the three staff nurses within the PHC premises would
address the health needs of the rural population in a very significant
manner. The Government of India would bear the entire capital
expenditure for construction/ repair/ innovation/ redesign of the buildings
in a phased manner over the mission period, excluding those already
taken up under the RCH-II.
In respect of new PHCs Centre would assist the States with the recurring
expenditure on 75:25 basis during the Eleventh Plan and on 50:50 basis
during the Twelfth Plan.
Rogi Kalyan Samiti would be constituted at the PHC level. To encourage
the states to do so, a grant of Rs. 1,00,000 is planned to be provided to the
states for each PHC for which a RKS has been constituted and where the
RKS has been authorized to retain the user fee at the institutional level for
its day to day needs.
The existing staff of disease control programmes would be integrated at
the PHC level and the RKS would be encouraged to rationalize the
manpower and equipments available under the vertical programmes for
greater synergy.
One AYUSH doctor would be posted at the PHC level. AYUSH drugs would
also be made available in adequate quantity.
30
The PHC would be managed by the RKS. The entire Budget allocated for
the PHC would be provided to the Samiti, which has PRI/Community
participation. The Samiti should own the institution.
CHC level
The CHCs are currently provided on the population norm of 1 per 1,20,000
population in general areas and 1 per 80,000 population in tribal / desert
areas. Even by 1991 population norms, against a requirement of 5587, if
we ignore the excess in some of the states, there is a shortfall of 2474
CHCs. Going by the population of 2001, the requirement goes up to 6491
and the deficit increases to 3332. Of these CHCs, as many as 318 do not
have their own buildings.
In some places, there are multiple health facilities being controlled by
different agencies. As a result, because of the manpower and equipment
shortage, none of the facilities function in an optimal manner. The States
would be asked to merge these facilities existing at the CHC headquarter
for better cohesion.
The location of the CHCs and the norms would be reexamined by the
States while preparing the District / State Plan.
The Centre would support the entire capital expenditure for the
construction of the new CHCs and the renovation of the existing CHC
buildings ( except those taken up under RCH-II).
The CHC should be managed by the PRI at the district level through RKS.
31
IPHS have been set up for the CHC level. IPHS is a novel concept to fix
benchmarks of infrastructure including building, manpower, equipments,
drugs, quality assurance through introduction of treatment protocols. All
CHCs to be upgraded to the IPHS in a phased manner manner over the
Mission period. The Govt, of India would bear the additional expenditure
to be incurred by the states on account of the IPHS fully during the
Eleventh Plan and in the ratio of 50:50 during the Twelfth Plan.
A support of Rs one lakh per CHC to be given to the Hospital
Management Society through states where those are authorized to retain
the user charges at the institution level. Five lakh for similar arrangement at
the District Hospital.
Accountability to public to be enforced through a prominently displayed
Citizens Charter (indicating the range of services and the rights of citizens)
to be monitored through Hospital Management Society.
Each district would be supported with one mobile medical unit which
would be attached to the district hospital / CHC. The states would be
encouraged to devise their own PPP mechanism for running the vehicle.
The states would be given flexibility to adopt the model they consider
appropriate.
AYUSH units to be set up in every CHC.
32
Term of Reference - vi
(vi)
To review disease control programmes and disease surveillance
mechanism in the country, its capability to provide up-to-date information
for effective timely response to prevent/iimit disease out breaks and to
provide effective relief measures.
The Working Group on Communicable and Non-Communicable Diseases
in their Report have examined in detail and reviewed the progress achieved in
respect of different Disease Control Programmes and the Disease Surveillance
mechanisms and suggested the action plan for the Eleventh Plan. In view of this,
in the present report the salient findings emerging from the detailed review
undertaken by the above mentioned Working Group in respect of some of the
major disease control programmes have been highlighted.
ISSUES OF PUBLIC POLICY:
The Working Group on Communicable and Non-Communicable Diseases
is of the view that there are two factors of critical importance to public policy
which need to be addressed:
identified
and
most
Programmes
in
which
almost
all
diseases
conditions
particularly
the
National
Health
(a) For
government investment was substantial i.e. Malaria and other
Vector Borne Diseases, T.B., Leprosy, Reproductive Health and
Childhood conditions, there is a paucity of high quality
epidemiological information and validated data.
In the
absence of operational research there was also weak evidence
regarding the type of interventions that would be most effective
in the different settings of the country and
(b) A literature review has thrown up evidence of a large number
of diseases which are considered to be life style related and
affecting the rich to be seen to be affecting the poor as well
and increasingly so.
33
1.
NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME
During the XI Plan period, the existing strategies for prevention & control of
vector borne diseases would be continued and further strengthened with special
emphasis on surveillance, human resource development, behaviour change
communication, supervision and monitoring, quality assurance and quality
control of diagnostics, drugs and operational research. The Programme aims to
maintain Annual Blood Smear Examination Rate of over 10% and bring down the
Annual Parasite Incidence to 1.3 or less so as to accomplish 25 per cent
reduction in malaria mortality by 2010 and 50 per cent by 2012.
Towards elimination of Lymphatic Filariasis, eligible population living in
endemic districts will be covered under Mass Drug Administration with single
recommended dose of DEC or DEC + Albendazole. For the patients, home
based morbidity management and hydrocele operations will be augmented.
Towards Kala-azar elimination, the annual incidence will be reduced to less than
1 per 10,000 population at the sub-district level by 2010. Control of Dengue and
JE is targeted at reduction of case fatality and frequency of outbreaks. To deal
with 50% shortage of MPW (M), it is proposed to fill up 25% of the vacant posts
through contractual schemes by Government of India, while the states will be
impressed to meet the funds requirement for remaining 25% posts.
2.
NATIONAL LEPROSY ERADICATION PROGRAMME
During the XI Plan, the programme will aim at further reducing the leprosy
burden in the country while providing high quality leprosy services for all persons
affected by leprosy to General Health Care System. Enhanced emphasis will be
laid on Disability Prevention & Medical Rehabilitation (DPMR) services for leprosy
affected persons. Further advocacy efforts will be continued in order to reduce
stigma and stop discrimination against leprosy affected persons and their
families. The programme will continue to receive free supply of MDT from
34
NOVARTIS
through
WHO
the
till
2010.
Partners
in
leprosy
programme
implementation like the WHO and International Federation of Anti-Leprosy
Association (ILEP) will continue to provide additional technical and monitoring
support to the programme.
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
3.
Based
on
the
earlier
programme
experience,
the
Project
Implementation plan of Phase II of RNTCP intends to strengthen the ongoing TB
control activities and support new initiatives viz. management of MDR TB using
DOTS Plus, strengthening State level laboratory network to undertake culture and
sensitivity testing, pediatric patient wise drug boxes, etc, During the period nearly
30 million TB suspects would be examined, and would help in diagnosing and
initiating over 6 million TB patients on treatment, of which nearly 3 million would
be infectious sputum positive patients and successfully treat over 85% of new
sputum positive registered patients.
NATIONAL AIDS CONTROL PROGRAMME
4.
The NACP-III during XI plan period of 2007-2012 has set the goal to
halt and reverse the epidemic in India over the next 5 years by integrating
programmes for prevention, care, support and treatment. This will be achieved
through four strategic objectives namely:
1.
Prevention of new infections in high risk groups and general population
through:
a. Saturation of coverage of high risk groups with targeted interventions
(Tls)
b. Scaled up interventions in the general population.
2.
Increasing the proportion of people living with HIV/AIDS who receive care,
support and treatment.
35
Strengthening
3.
the
infrastructure,
system
and
human
resource
in
prevention, care support and treatment programmes at the district, state
and national levels.
Strengthening a nation-wide strategic intormation management system.
4.
The specific objective is to reduce new infections as estimated in year 1 of
the programme by:
■
Sixty percent (60%) in high prevalence states so as to obtain the reversal
of the epidemic; and
■
Forty percent (40%) in the vulnerable states so as to stabilize the
epidemics.
Based on the lessons learnt from the previous two phases, the NACP-III will
be strengthened during the XI plan period. The priorities and thrust areas will
include prevention; care, support and treatment; capacity strengthening; and
strategic information management.
Non-Communicable Diseases
Unlike the communicable diseases the NCDs are linked to a cluster of
major risk factors such as tobacco use, unhealthy diet, physical inactivity,
obesity, high blood pressure, cholesterol and glucose levels that are
measurable and largely modifiable. Presently, there are national programmes
for Cancer, Blindness, Mental Health and Iodine Deficiency Disorders.
Reviewing these programmes and analyzing the kind of ailments/diseases
which are emerging, the salient recommendations made by the Working
Group in their report on communicable and non-communicable diseases are
given below.
36
National Cancer Control Programme
The National Task Force that had been set up under the programme has
made a series of recommendations for cancer control during the Xlth Plan. The
strategies proposed include prevention and early detection of cancer through
District Cancer Control activities, strengthening IEC, promoting centres of
excellence in the field of cancer management, augmenting cancer care
facilities across the country, development of early diagnostic capabilities and
increasing capacity for palliative care in cancer etc. This is to be achieved
through encouraging Public Private Partnership, heath advocacy, capacity
building and promoting research.
National Programme for Control of Blindness
Prevalence and cause of blindness have undergone a distinctive change
since launching of the National Programme for Control of Blindness as shown
below:
Year
1971-74
1986-89
Prevalance
1.38%
1.49%
2001-04
1.10%
2007
2010
2020
0.8%
0.5%
0.3%
Remarks___________________________________
Cataract leading cause (75%)
Cataract Blindness increased to 80%, Trachoma
and Vitamin A related blindness reduced
Cataract reduced to 63%, Refractive Error second
leading cause (20%), Glaucoma and Diabetic
Retinopathy emerging causes_________________
Goal for 10th plan____________________________
Goal indicated in National Health Policy
Goal under “Vision 2020 initiative”
The main causes of blindness in this population are as follows: A
B
C
D
E
F
G
H
Cataract___________________
Refractive Error______________
Corneal Blindness____________
Glaucoma_________________
Surgical Complication________
Posterior Capsular Opacification
Posterior Segment Disorder____
Others
_____________
62,6%
19.70%
0.90%
5.80%
1.20%
0.90%
4.70%
4.19%
37
There are no nation-wide reliable data on refractive error and low-vision
among children in the country except some isolated studies.
Among the
emerging causes of blindness, diabetic retinopathy and glaucoma need special
mention. 2% of India’s population is expected to be diabetic. 20% of diabetics
have diabetic retinopathy and this number is likely to grow in future. Prevalence
of blindness due to glaucoma is estimated to be 4% in population aged 50 years
and above.
To intensify and accelerate the present prevention of blindness activities,
so as to achieve the goal of eliminating avoidable blindness by the year 2020.
The major focus areas for the Xlth Plan are:
J Refractive Error
J Low Vision
Childhood Blindness including Vitamin A deficiency.
z
Corneal Blindness including Trachoma.
Z Emerging Causes, Glaucoma, Diabetic Retinopathy.
The
Working
Group
has recommended
setting
up
a
Eye
Care
Management Information and Communications Network Project to support
access to quality and affordable eye care services for prevention of blindness
and sight restoration to the underserved population. The national network will
comprise the District Blindness Control Societies, private hospitals, regional
institutes of ophthalmology and centres of excellence. The latter centres would
provide speciality services under one roof with highly trained and motivated
professionals. The new initiatives proposed includes construction of dedicated
eye wards and operation theatres in district hospitals in the North-eastern States,
Bihar, Jharkhand, Jammu & Kashmir, Himachal Pradesh, Uttaranchal and other
States on demand. Telemedicine in ophthalmology is also to be promoted.
38
National Mental Health Programme
Based on the review of the existing programme, a revised programme is
proposed to be taken up with the objectives to empower the doctors in the
primary care facilities to be able to offer care to patients at PHCs, improve
public awareness and facilitate community participation, upgrade psychiatry
departments of medical colleges and improve mental hospitals that offer tertiary
care.
National Iodine Deficiency Disorders Programme
It is proposed to bring down prevalence of IDD below 10% in the entire
country by 2012 AD and ensure 100% consumption of adequately iodated salt
(15 PPM) at the household level through IDD surveys through State Govts./NGOs
establish IDD Control Cells, and IDD monitoring labs, quality control of iodated
salt at the consumer level, training programme, production and distribution of
iodated salt, health education and publicity and pilot programme for the control
of micronutrient deficiencies.
New Initiatives:
National programmes are likely to be taken up for prevention and control
of diabetes, cardiovascular diseases and a programme for the healthcare of the
elderly.
INTEGRATED DISEASE SURVEILLANCE PROJECT
State level workshops in Tamil Nadu, Maharashtra and Uttar Pradesh were
held which brought out the following issues on the current disease surveillance
activities:-
39
Primary level
Active or passive data collection is going on for more than 60-90 different
conditions in some of the states The peripheral data collection system is over
burdened with a substantial percentage of the time of the ANM spent on
surveillance related activities Quality of reporting is hampered by absence of
clear case definitions Data transmission is affected by poor communication
facilities available Absence of formats for reporting diseases adversely affect
quality of the data collect. There is no horizontal integration of surveillance
activities of existing disease control programs Data is not collected from private
practitioners, private laboratories and private hospitals both in rural and urban
setting as well as medical colleges. Infrastructure for urban surveillance is very
weak in view of the rapid growth in urban populations
There is no system of feedback to the lower levels of the health system.
Data collection during emergencies and epidemics is of better quality There is
no system of quality control for the data collected and there is very little analysis
and action based on the data District level Quality of data collected is poor
Analysis of data is inadequate for meaningful interpretation The laid down
protocols were not being followed and needed to be activated District level
response system is activated only in times of outbreak Non-Communicable
Diseases are not included in surveillance even though the burden due to them is
high The information is not shared across disease control Programmes There is
lack of coordination between departments District administrative system is not
able to make use of the health data State level There is need to improve the
quality of data in terms of reliability and validity There is problem of timeliness as
data is transmitted to state head quarters irregularly and often late. Most of the
data received at the state level is not analyzed Data is not used for routine
Programme planning There is need to improve human resources
40
The IDSP taken up as a plan scheme and launched in November, 2004 for
improving disease surveillance and response through an integrated approach
with rational use of resources for disease control and prevention. Data collected
under IDSP would also provide a rational basis for decision making and
implementing public health interventions.
Specific objectives of the IDSP ore:
> To establish a decentralized district-based system of surveillance for
communicable and non-communicable diseases so that timely and
effective public health actions can be initiated in response to health
challenges in the urban and rural areas
> To integrate existing surveillance activities (to the extent possible without
having a negative impact on their activities) so as to avoid duplication
and
facilitate
sharing
of
information
across
all
disease
control
programmes and other stake holders, so that valid data are available for
decision making at district, state and national levels.
Features of Integrated Disease Surveillance are as follows:
> The district level is the focus for integrating surveillance functions.
> All surveillance activities are coordinated and streamlined. Rather than
using scarce resources to maintain vertical activities, resources are
combined to collect information from a single focal point at each level.
> Several activities are combined into one integral activity to take
advantage of similar surveillance functions, skills, resources and target
populations.
> The IDSP integrates both public and private sector by involving the private
practitioners, private hospitals, private labs, NGOs, etc and by active
community participation.
41
> The IDSP integrates communicable and non-communicable diseases.
Common to both of them are their purpose in describing the health
problem, monitoring trends, estimating the health burden and evaluating
programmes for prevention and control.
> Integration of both rural and urban health systems as rapid urbanization
has resulted in the health services not keeping pace with the growing
needs of the urban populace.
> The gaps in receiving health information from the urban areas needs to
be bridged urgently.
> Integration with the medical colleges (both private and public) would
also qualitatively improve the disease surveillance especially through
better coverage.
DISEASES UNDER SURVEILLANCE
Core Diseases
Regular Surveillance:
Vector Borne Disease
Water Borne Disease
Respiratory Diseases
Vaccine Preventable Diseases
Diseases under eradication
Other Conditions
: 1. Malaria
: 2. Acute Diarrhoeal Disease (Cholera)
: 3. Typhoid
: 4. Tuberculosis
: 5. Measles
: 6. Polio
: 7. Road Tratfic Accidents
Other International commitments:
42
8. Plague, Yellow fever
Unusual clinical syndromes:
9. Menigoencephalitis/Respiratory Distress
(Causing
death
/
hospitalization)
Hemorragic fevers,
other undiagnosed
conditions
Sentinel Surveillance:
Sexually transmitted diseases/
Blood borne :
10. HIV/HBV, HCV
Other Conditions:
11. Water Quality
12. Outdoor Air Quality (Large Urban centers)
Regular periodic surveys:
NOD Risk Factors:
13. Anthropometry, Physical Activity, Blood
Pressure, Tobacco, Diet etc.
State specific diseases:
Each State can include up to 5 diseases prevalent in the State.
PROJECT PHASING
The Project would cover the entire country in a phased manner as
depicted below:
Phase I (commencing from FY 2004-05) Andhra Pradesh, Himachal Pradesh,
Karnataka, Madhya Pradesh, Maharashtra, Uttaranchal, Tamil Nadu, Mizoram &
Kerala.
Phase II (commencing from FY 2005-06) Chhatisgarh, Goa, Gujarat, Haryana,
Rajasthan, West Bengal, Manipur, Meghalaya, Orissa, Tripura, Chandigarh,
Pondicherry, Delhi & Nagaland
43
Phase III (commencing from FY 2006-07) Uttar Pradesh, Bihar, Jammu & Kashmir,
Jharkhand, Punjab, Arunachal Pradesh, Assam, Sikkim, A & N Nicobar, D & N
Haveli, Daman & Diu, & Lakshdweep
Development of Software for Disease Surveillance
A software will be developed for data entry, compilation, analysis and CIS
to facilitate Disease Surveillance. Nation-wide web connectivity would be
provided under the project. A typical District Surveillance Network is depicted
below:
CENTRAL LEVEL
A National Disease Surveillance Committee has been set up at the
national level to arrive at
>
Major policy decisions in implementing IDSP
>
Review Physical and Financial progress in implementing IDSP
>
Coordination with all relevant Ministries, Departments and Organizations.
The Central Surveillance Unit (IDSP) will be supported by Surveillance Committees
at the State and district levels.
44
Term of Reference-viii
(viii)
To suggest modification in policies, priorities and programmes during
11th Plan period in relation to:
(a) Priority areas of research to investigate alternative strategies;
(b) Mid-course correction of ongoing activities;
(c) New initiatives;
(d) Strategies to improve quality and coverage of services at
affordable cost, to cope with existing, reemerging and new
challenges in communicable diseases, emerging problems of noncommunicable diseases due to increasing longevity, life style
changes and environmental degradation;
(e) Provide all these services through NRHM and secondary health
care system in an integrated fashion;
(f) Improve disease surveillance, HMIS, effective timely response.
The health scenario in India is at the cross roads at the present juncture.
Changing epidemiological profile requires changes in the demand for health
service and health promotion measures.
The emphasis on changing Disease
control priorities have been highlighted in the earlier sections and analyzed indepth by the Working Group on Communicable and Non-Communicable
Diseases.
The healthcare delivery system will need to gear up to address the
demographic transition, the epidemiological transition, changing risk environment
and the consequential widening in the gap between health problems and needs
on the one hand and provision of healthcare services on the other.
The demographic transition itself is likely to witness a decline in mortality and
fertility rate with the improvements being effected in healthcare prevention and
cure and general levels of economic betterment. Alongside the country will also
be witnessing an increasingly ageing population. The age pyramid that has been
projected indicates that during the period 1996-2016, the following changes are
likely to occur:
.
Population in the age group less than 15 years is likely to decline from 353
to 350 million
45
•
Population in the age group 15-59 years is likely to increase from 590 to
800 million
•
Population in the age group greater than 60 years is projected to increase
from 62.3 to 112.9 million.
The increase in the ageing population will bring along with it many chronic
diseases like cancer, diabetes, CVDs etc. which will tend to be high in the older
age groups.
These would require to be addressed through an integrated
healthcare plan. The manner in which this is proposed to be done has been
outlined under the Term of Reference (iv) discussed earlier.
In the epidemiological transition, communicable diseases particularly AIDS
and other life style diseases will require to be addressed. In so far as
communicable and non-communicable diseases are concerned, the emphasis
will be on operational research for collating impact of interventions already
undertaken so that the targeted measures to be taken will be more cost
effective and outcome based.
Health advocacy and health education
promotion would be given renewed emphasis given the present scenario of life
style related diseases and the future inroads this is to make in the healthcare
delivery system. Risk factors like tobacco abuse have already been addressed
and become entrenched in the policy structures with legislative support.
Adequate safeguards would need to be taken through promoting exercise,
yoga and healthy diets particularly in the younger population as preventive
steps for tackling life-style diseases.
The demand for health services in the future is likely to be phenomenal
with increases in the health seeking behaviour resulting from better levels of
education, income status and urbanization. The National Rural Health Mission in
a way addresses issues relating to most of these aspects of healthcare. The
priorities are and will continue to be maternal and child health, life style related
diseases and healthcare for the aged. Accidents and trauma care will also be
another important priority that would be addressed. The Health Policy is veering
46
towards an integrated healthcare delivery system whereby treatment of a
patient is not limited by any disease or ailment but his treatment is visualized in a
holistic manner. This is being attempted through the mission approach with the
integration of the disease control programmes with the general healthcare
system. Community led action with close involvement of Panchayati Raj
Institutions and local bodies and setting up of Rogi Kalyan Samitis are likely to
enhance accountability and shift the focus of healthcare efforts around the
individual. Pooling of resources particularly medical and para-medical support,
managerial assistance at the State and the district levels for proper
accountability of funds released and a shift from merely curative to preventive
and promotive healthcare as being envisaged in the Rural Health Mission are
likely to make an impact on the health status profile of the population.
Integrating the major healthcare schemes and programmes under a common
umbrella is also likely to maximize health outcomes with optimal utilization of
resources.
Health and Family Welfare programmes by forming an integrated
component is likely to pool in medical manpower in most of the rural areas.
The inter-sectoral convergence already initiated under NRHM will need to
be strengthened in the future.
In so far as women and children are concerned, the areas of
convergence would need to lie in nutrition and women's empowerment. Under
the NRHM, the anganwadi is already identified as the hub of action with a health
and nutrition day being observed on a monthly basis. Support to the ANM and
AWW would be through the untied fund.
On the education front the areas of convergence would be in school
health education for promoting primary healthcare and adolescent health. The
school health programmes have already been integrated in programmes like
Blindness Control and RCH-II and will be given a further boost in the future.
47
Safe drinking water and sanitation are areas that have been taken up
under the NRHM for effective convergence.
The Village Health Sanitation
Committee will cover all activities relating to drinking water, sanitation etc. ASHA
will be associated with the water quality monitoring and surveillance programme
and total sanitation campaign.
The Panchayati Raj Institutions will be fully
involved in this convergent approach so that the gains of integrated action can
be reflected in the district health plans. The NRHM would seek to empower PRIs
at each level i.e. Gram Panchayat, Panchayat Samiti at Block level and Zila
Parishad at District level to assume leadership to control and manage the public
infrastructure structure at district and sub district levels. Under the NRHM, it is
proposed to build an accountability framework through a process of community
based monitoring, external surveys and stringent internal monitoring.
Capacity building of available medical and para medical manpower is
also visualized. Besides, training and putting in place 4 lakh ASHA/Community
health workers, the Mission will also provide 2 ANMs at each sub-health centre
and 3 staff nurses to ensure provision of services round the clock in every PHC.
The CHCs are also to be brought at par with Indian Public Health standards to
provide round the clock hospital like services. This is to be achieved through 7
specialists as against 4 at present and 9 staff nurses as against 7 at present in
every CHC. A separate AYUSH set up would also be provided for in each PHC
and CHC. Incentives will also be provided to ensure that doctors do continue to
serve in the rural areas by residing in those areas and not by commuting from the
nearby towns or headquarters.
Medical nursing education will also be
revamped to cater to the growing needs of healthcare.
New initiatives in the nature of National Programmes for Diabetes,
Deafness and CVDs will be taken up in the 11th Five Year Plan. Besides National
Institute for the Aged supported by the regional centres is also proposed.
48
Term of Reference - IX
(ix)
To indicate manpower requirement and financial outlays required for
implementation of these programmes during the 11th Plan period;
As per the 2001 Census, 741.7 million of India’s population resides in rural
areas spread over 638,588 villages and more than 10 lakh hamlets and
habitations. The challenge of health care in rural areas is to be able to reach out
to these widely disbursed and remote habitations in a meaningful way.
The
approach so far has been to provide a Sub-Health Centre for a population of
5000, a Primary Health Centre for a population of 30000 and a Community
Health Centre for a population of one lakh with marginal alterations for hilly and
desert areas.
The human resource challenge
The biggest challenge of the public health system is to provide adequate
resources along with essential reforms to make it deliver better, with community
ownership and accountability. The fundamental issue is to resolve the crisis of
the public health system in terms of availability of health and para medical staff
in rural areas. New and innovative ways of management of human resources
(Clusterized posting at Block/CHC level, incentives, career progression, specialist
training, multi skilling, etc.) would have to be evolved in state specific contexts to
ensure availability of personnel in remote regions. Priority will also have to be
accorded to filling up of vacancies of ANMs, Nurses, Para Medical Staff, Block
Medical Officers, key Specialists, etc. It is important to have local residence
criteria for remote regions as often outsiders, even if recruited, are found to be
absent or seeking a transfer out of such regions. Systems of engaging local
women and providing them sustained support to develop as ANMs and Nurses
could also be considered.
49
An analysis of availability of ANMs across States show that in States like
Tamil Nadu and Kerala, an individual ANM caters to much fewer villages and
population wherein in States like Chhatisgarh, Madhya Pradesh and Uttar
Pradesh, the number of villages and population are much larger.
To a
considerable extent this affects her quality of delivery and maybe it would be
desirable to move towards a norm that combines work load, distance,
population and community convenience. The high levels of absenteeism among
health workers and doctors in rural areas is another factor that needs to be
borne in mind. This calls for an approach that improves the accountability
framework and also allows development of local residents as health workers.
Public Health System in rural areas
•
There are 1,46,026 Sub Health Centres, 23,236 Primary Health Centres, and
3346 Community Health Centres.
•
As per 2001 population norm, another 19,269 Sub Health Centres, 4337
Primary Health Centres, and 3206 Community Health Centres should be
established to fulfill population norms for SHC/PHC/CHC.
State of infrastructure
•
60,762 existing SHCs, 2948 PHCs and 205 CHCs need buildings. Those that
have buildings do not get adequate resources for asset management,
maintenance, etc. remaining in a descript shape.
•
Community/User groups not involved in construction/maintenance of
facilities. Funds are centrally managed in most states.
•
Toilets, electricity, drinking water, equipment, medicines, not adequately
available in many institutions.
50
State of staff -1
Staff
Required
In Position
ANM
1,69,262
1,33,194
MPW (M)
1,46,026
61,907
HA (F)LHV
23,236
17,371
HA(M)
23,236
20,181
State of Staff- II
Staff
Required
In Position
Doctors at PHC
23,236
20,308
Surgeons at CHC
3346
1201
Gynaecologists at CHC
3346
1215
Paediatricians
3346
678
Staff
Required
In Position
Radiographer at CHC
3346
1337
Pharmacist at CHC &
26,582
17,708
26,582
12,284
46,658
28,930
State of staff-III
PHCs
Lab Technicians at CHC
& PHCs
Nurse Mid Wives at CHC
& PHCs
Source: Bulletin on Rural Health Statistics in India, 2006
Ministry of Health & Family Welfare
51
Areas of Concern
•
9869 PHCs are single doctor PHCs.
•
5769 Sub Health Centres are without ANMs.
•
Repair and maintenance grants to institutions are centralized, untimely
and inadequate, leading and dilapidated structures.
•
Contingencies are inadequate leading to lack of cleanliness and quality
of services.
•
Very high rate of absenteeism of staff.
Non-governmental provider in rural areas
•
Range of providers - Trusts, NGOs quacks, ISM / Allopathic practitioners,
private nursing homes, clinics, etc.
•
Round the clock availability in many cases. Can be reached during an
emergency.
•
Unregulated fee and non standard treatment protocols - the ' saline -
syringe syndrome'.
•
Leads to high out of pocket expenditures.
Overhaul of the Public health system
•
Calls for 'communitization' of the health system - PRI and user groups at
each level.
•
Pooling of resources and optimal utilizationy.
•
Decentralization for institutional autonomy.
•
Decentralized local area planning with household and facility surveys.
•
Providing 24 hour round the clock hospital like services in every Block.
52
Managing for performance
Human resource
actions
Workforce
objectives
• Numeric adequacy
•Skill mix
•Social outreach
Coverage:
Social and
physical
•Satisfactory
remuneration
•Work environment
•Systems support
Motivation:
Systems and
support
•Appropriate skills
•Training and
learning
•Leadership and
entrepreneurship
/
Training and
learning
Health
outcomes
Health
system
performance
Equitable
access
Efficiency
\
and
effectiveness j
7
Health of
the
population
Quality
And
responsiveness
53
Management of Health System
TASKS
Supervision of services
Training of community
Survey and mobilization
Distribution of drugs
Monitoring/Reporting
Planning and MIS
Capacity building
Mapping NGOs
Financial Management
Procurement/Stores
Technical/Community
Planning and MIS
Capacity building
Financial Management
Procurement/Stores
Technical/Communil,
LEVEL
Block Level Health
Team
District Level
Health Team
State Level Health
Team
TEAM
Block Medical Officer
Block Resource Group
Accountant
Data Entry Assistant
Store Keeper
DM-DMHO
Mgt Expt. As ADHMO
Finance/Data/Proc.
Tech./NGO/Community
Mission Director
Coordinators Technical, Financial,
MIS, M&E, Gender,
NGO, Procurement,
54
Building Capacity through Resource Groups
TASKS
Training
PRIs/CBOs
Surveys/MIS
Training
LEVEL
TEAM
BLOCK
LEVEL
Block Health Office
Block Resource Team
RPs
DISTRICT
LEVEL
District Resource
Group; PMU;
Specially recruited
skills ; DHM
STATE
LEVEL
State level Mission
SIHFW/lnstns./NGOs
Resource Centre
of
Surveys/MIS/NGO
Procurement/Data
Training/M&E
Financial Mqt.
Studies/Supervision
Procurement/MIS
Training/Planning
FMZ M&E/NGOs
Planning/supervisio
n
MIS/M&E/Proc./FM
NGOs/Community
NATIONAL
LEVEL
NHSRC/NIHFW
MoHFW
Institutions
55
Communitization of Health Care
TASKS
LEVEL
TEAM
Community action
Survey/Support
Planning/
Village Health &
Sanitation
Committee
ASHA/AWW/P
Rl
SHG/CBO
Planning/Survey
Community action
Implementation
Sub Health
Centre level,
Gram Panchayat
Sam iti
ANM/MPW
PRI/NGO
Women’s
Planning/ Support
Supervision
Community action
PHC level cluster
level Committee
Planning/
Implementation/
accountability
Public Hearings
■ ■
■■■
■
___
Planning/ M&E/
Supervision
Accountability
ciHC/BiocKPHC/
BMO level
Panchayat
Samiti/ RKS
District level
Health Mission
under the Zila
Parisshari
PHC MO/ Para
Medics
NGO/PRI
Women's
BHO; RKS of
CHC;
Panchayat
Samiti
Zila Parishad;
DM/CEO/DMH
O
56
Under the NRHM, the Public Health System will be strengthened at all
levels. In the changed scheme at things, there would be 2 health workers and 1
voluntary work in each sub-centre, a mix of technical and administrative staff
numbering 15 in new Primary Health Centres, a strength of 25 Community Health
Centres. Besides additional staff would be provided at the different levels for
achieving the IPHS standards. At the PHC there would be an additional medical
officer and two staff nurses. While at the CHC the supportive staff would be 6-7
consisting of specialists, surgeons, anesthetist etc. The CHC will be additional
provided with
supportive
manpower which will include technical and
administrative staff.
The financial outlays required for strengthening manpower has been
reflected under NRHM and is given in Annexure-X.
57
Recommendations
1.
Access to clean drinking water will need to be planned for and rigorously
implemented.
2.
Need to take stock of the habitation survey on Rural Water Supply System
that was conducted in 2003 which has indicated large incidences of slippage
from fully covered to partially/ not covered categories due to a number of
factors such as services going dry, lowering of ground water levels, system
outliving their lives and increase in population resulting in global per capita
availability. The action plan under drinking water supply would then need to be
suitably redesigned and operationalized.
3.
Sanitation is another important factor decelerating improvements in
health status.
The position regarding connectivity for waste water across
different States is alarming and would need to be addressed on priority in
coordination with the Department of Drinking Water and Sanitation as lack of
adequate sanitation is responsible for severe health problems. In fact cholera,
dysentery, typhoid, infectious hepatitis and many other diseases can be traced
to the unsanitary disposal of human excreta.
ASHA should have a bathroom in
her house.
4.
The social consequences of lack of sanitation has given rise to manual
scavenging which is banned. A sanitation movement both in the interest of
social equity and prevention of diseases is to be taken up on a priority basis. All
dry buckets should be converted to two pit compost flush toilet. All sanitation
workers are to be provided with protective gear and medically examined
annually.
5. Explore replicating on a large scale the experience ot Sulabh Shauchalaya a
low-cost sanitation technology.
58
6.
Consider introducing where not already done toilet complexes with
biogas plants in respect of district/taluka hospitals and CHCs.
7.
Introduce environmental sanitation in all schools in the rural areas/urban
slums etc.
8.
To promote health education and awareness particularly with respect to
drinking water and sanitation, consider the SWAJAL Project of U.P. being
implemented with World Bank assistance that not only aims at providing drinking
water in rural areas but covering a range of development initiatives including
non-formal education, hygiene and environmental sanitation awareness and
women's development initiatives.
9. Distribution of key micronutrients and addressing the problem of nutrition and
anemia among women and children.
10.
Building up an effective health system capacity so as to clearly focus on
important health outcomes spelt out in National Health Policy 2002. The outputs
to be achieved and outcomes projected to be in line with the Millennium
Development Goals.
11. Broader range of drug regimens to be considered. A systematic effort to be
made to analyze which approaches work and those which do not.
12.
Promote high volume care for lower surgical procedures like cataract
surgery where lower level workers could be appropriately trained to substitute for
more expensive and difficult cases/surgeries.
13. Promotion of exercise and yoga as stress reducing factors to help in arresting
obesity, diabetes and other life-style diseases.
59
14.
Need to bring about a shift from specific project to programme support.
Also ensure that releases are performance based with focus on final outcomes
as in the case of RCH Phase-ll.
15. Focus public resources for revitalizing and strengthening public facilities in
disadvantaged areas and consider the feasibility/desirability of purchasing
curative care from the private sector.
16.
Professionalize service delivery by appropriate measures for increasing the
number and quality of medical and nursing colleges.
Ensure distributive equity across States by encouraging establishment
of new medical colleges where there is a shortage.
Increase public investment in the poor performing States to establish
medical/nursing colleges or alternatively provide incentives to the
private sector to set them up and regulate them effectively so as to
ensure that there is no compromise in the standards and quality of
care.
Draw up an action plan to fill up the vacancies of the teaching faculty
in medical colleges.
Consider reviving the scheme of reorientation of medical education
programme for preparing doctors to work in rural communities.
Improve payment systems and design suitable incentives particularly
housing and other facilities for retaining skilled doctors and specialists
from moving into the private sector.
17. Better motivation and periodic training for multi-purpose workers and ANMs.
Improvements to be also effected in the quality of training for nurses. According
to the NCMH in 2004, 61.2% of nursing schools/colleges were found to be
unsuitable for teaching. Though these were derecognized by the Indian Nursing
Council they have no impact as they continue to function with a permission of
State Nursing Council.
60
18. Uniform system of reporting of data by the State and their validation is very
essential for policy making. The format designed for NRHM would be the starting
point but efforts will need to be made to monitor data relating to outputs set
against the outcomes envisaged. This will involve coordinating with other related
Departments as public health services including water and sanitation cuts across
different players at the Central and State levels.
19. Availability of timely data on physical progress would have a bearing on the
allocations to be made under different services/segments within and outside
health.
The impact of these changing allocations alongwith expenditure
incurred will need to be tracked appropriately through matrices in national
health accounts. The National Health Accounts brought out for 2001-02 should
be continued on an annual basis and systematically refined to act as a tool to
policy makers for making investment decisions and tracking financial flows in the
health sector.
61
REPORT OF THE WORKING GROUP ON
HEALTH OF WOMEN AND CHILDREN
FOR THE
ELEVENTH FIVE YEAR PLAN
(2007-2012)
Ji; xm
WM T-H
GOVERNMENT OF INDIA
PLANNING COMMISSION
NEW DELHI
1
CHAPTER - 1
INTRODUCTION
This Working Group under the Chairmanships of the Secretary (H&FW) was
formed in the context of formulation of the Eleventh Five Year Plan (2007-12) and was to
deliberate on issues related to health of Women & Children. The composition of the
working Group is given in Annexure I. Following were the specific terms of reference
for the Group.
i)
ii)
iii)
iv)
v)
vi)
Assessment of procedures for estimating Mortality/Morbidity in women &
children.
Review of ongoing major Reproductive and Child Health programmes.
Review of the functioning of family welfare infrastructure and manpower in
rural and urban areas and suggesting measures for rationalizing, restructuring
the infrastructure, strategies for improving efficiencies of implementation of
the programme and for the delivery of services.
Methods for improving Reproductive and Child Health activities at secondary
and tertiary care levels.
Projecting financial/ physical requirements for implementation of these
programmes during the Eleventh plan.
Other recommendations relevant to the above topics.
2. While deliberating on the tasks assigned to it, the Working Group took note of the
strategies and approaches articulated in the National Programme Implementation Plan
(PIP) for the second phase of the Reproductive and Child Health (RCH-II),
Implementation Framework document for the National Rural Health Mission
(NRHM), findings / recommendations made by the National Commission on
Macroeconomics and Health (NCMH), 10th Plan Mid-term Appraisal document,
Approach Paper (draft) for the 11th Plan prepared by the Planning Commission and
documents prepared by other stakeholders.
3. The Working Group noted that the NRHM holds the biggest potential so far for
improvement in the health status of women and children, making it possible thereby
to achieve the MDG goals. The Broad Framework for Implementation of NRHM is
given in Annexure II. However, the challenge lies in the implementation of the
Mission particularly in tackling the issues identified in the 11th Plan Approach Paper
2
prepared by the Planning Commission, namely, non-availability absenteeism of
doctors/health providers in the rural areas, low levels of skills in medical
professionals , inadequate supervision/monitoring of the programme etc.
The Working Group was of view that while NRHM and RCH-II address many critical
issues of concern to the health of women and children, the ambit of these programmes
needs to be widened in the 11th Plan to address additional concerns. Therefore, an
attempt has been made to prepare a self-contained document responding to the issues
to be considered, keeping in view the strategies and interventions already included in
the RCH-II and the NRHM, however, suggesting what needs to be done beyond these
programmes.
*****
3
CHAPTER - 2
A REVIEW OF PROCEDURES FOR ESTIMATING MORTALITY AND
MORBIDITY IN WOMEN AND CHILDREN
1. Mortality and morbidity indicators in a country provide a broad profile of the
status of its health and economic conditions and also reflects the lifestyle of the
people contributing to chronic diseases. Such data also reflect the responsiveness
of the health institutions in tackling major diseases; and chronic conditions like
obesity, malnutrition, eating habits, geriatric conditions etc, the geographical
spread of the incidence; and other related factors.. Though such data is typically
culled out from available records like death certificates, municipal records,
hospital records, etc, it is often corroborated through random surveys of the
household. In India, the Registration of Births and Deaths Act, 1969 (RBD) is
coordinated and administered by the Registrar General and Census Commissioner
of India (RGI) and designated State level authorities in the State Govts. Though
the registration of births and deaths is mandatory under the RBD Act, yet the
extent of registration of births and deaths is not satisfactory across the states.
Consequently, the proportion of births and deaths that are reported and registered
through the official machinery, on an average, is only around 58% and 54%
respectively. To supplement it, the Sample Registration System (SRS) of the RGI
also provides periodic estimates of births, deaths, mortality rates like CDR, IMR
etc. cross classified by rural-urban residence status and also by gender. The SRS
is a dual record system and involves continuous enumeration of births and deaths
in a sample of villages/ urban blocks by a resident part-time enumerator, followed
by an independent six monthly retrospective survey by a full-time supervisor. It is
perhaps the largest demographic sample survey in the world covering over a
million households and six million population. The Vital Statistics Division of the
Office of the Registrar General, India at national level, coordinates, looks after
implementation of the system, formulates and prescribes requisite standards,
provides appropriate instructions and guidance, and undertakes tabulation and
analysis of data and its dissemination in the form of SRS Bulletin, Annual Report
and Life Tables.
4
2. The RGI is taking various initiatives to improve the Civil Registration System
(CRS). However, these initiatives are mainly related to several provisions of the
RBD Act and mainly focus on how to improve administering the RBD Act, 1969,
like making people themselves responsible for registration of births and deaths
making penalities more stringent etc.. The proposed changes have been circulated
to the major stakeholders for their comments before a final shape is given to the
RBD Act. Another initiative being proposed is the National Photo-Identity Card
(NPIC) System, which is being conceived/evolved and is going to be piloted in a
few States. It is however relevant to mention that the success of any RBD activity
needs to be linked to the socio-economic life of its citizens. Thus the necessity of
a Birth Certificate for School admissions, passport etc; a Death Certificate for
property transfer to heirs ; media messages; etc are all such initiatives to improve
the CRS.
Mortality and Morbidity Indicators estimated through Surveys carried out under
MoHFWprogrammes
3. National Family Health Survey (NFHS) : The main feature of NFHS is to
provide important demographic and health database in India covering fertility and
family planning, mortality and morbidity, health, health care and nutrition and
also prevalence of HIV/AIDs. The first round of NFHS was conducted in 1992-93
and the second round
during 1998-99. The current survey of NFHS was
undertaken during 2005-06 covering 1.1 lakh households and interviewing about
2.3 lakh eligible men and women.
The results of a few states are being
disseminated while those at national level are expected during end of 2006-07.
4. District Level Household Surveys (DLHS): Since the indicators estimated
through SRS and NFHS are confined to state level only, the concept of providing
similar indicators at district level had been perceived through DLHS. While first
round of DLHS was undertaken in 1998-99, the second DLHS was undertaken
during 2002-04. The results of the second round of the DLHS (2002-2004) were
released in March, 2006 to serve as the Base-line survey for the NRHM. The
5
preparatory work for the third round of the DLHS (2006-2007) is on and would
serve as the Mid-line Survey of the NRHM. The DLHS-II covered 1000
households per district and the DLHS-III would have a varying sample size
ranging from 1000 to 1500 households in each of 600 odd districts in the country
depending on the variability of health parameters. The DLHS-III would yield
estimates for ANC and immunisation services, safe deliveries, contraceptive
prevalence rate, RTI/STI, HIV Aids, utilisation of services etc.
5. Worldwide, about 500,000 women die every year from pregnancy and childbirth
related causes and most of these deaths occur in developing countries (WHO,
1999). Reliable national estimates of maternal mortality are not available for most
countries since most of the demographic surveys do not have samples large
enough to produce reliable direct estimates of maternal mortality. Both NFHS and
SRS suffer from these limitations. However, an attempt had been made by the
office of the Registrar General of India to estimate MMR through verbal autopsy
and the results are expected shortly.
6. The successful implementation of NRHM and tracking the impact of interventions
under it require reliable estimates of mortality and morbidity at the district level.
Since none of the existing mechanisms provide district level estimates, there is an
urgent need to evolve a system that can provide suitably reliable district level
estimates of IMR, MMR, leading causes of death and morbidity.
7. Recently, the National Commission on Population (NCP), chaired by the Hon’ble
Prime Minister, desired that an Annual Health Survey (AHS) be carried out to
prepare a Health Profile of all the Districts in the country. The MoHFW explored
the feasibility of involving the machinery of the National Sample Survey
Organisation (NSSO) and the Registrar General of India. A Task Force has been
set up under the Chairmanship of Addl DG (Stats), MoHFW, to identify the list of
indicators that ought to be collected at the District-level, its frequency/ periodicity
and also to suggest the infrastructure required for undertaking the Survey. This
Task Force has met once and discussed various issues and alternatives as also the
6
status of the AHS vis-A-vis the DLHS and the machinery required for undertaking
the survey.
8. The RGI had submitted a proposal for undertaking the AHS by strengthening the
SRS network which was examined by the Task Force and it was of the opinion
that the proposal needs to be revised keeping in view the overall data
requirements (scope and periodicity) that would be necessary to prepare a District
Health Profile which could cover both morbidity and mortality aspects. The Task
Force was of the opinion that the major Health Indicators at the District Level do
not change that frequently and thus it would be economically and technically
desirable to spread out the survey work over a period of 2 to 3 years so that each
District is profiled once in 2 to 3 years. A revised proposal from the RGI is
awaited. Once the AHS is commenced and the process stabilised, the possibility
of phasing out the DLHS can also be explored.
9. The Government of India set up a permanent National Statistical Commission
(NSC) on 1st June 2005 and its members are from various fields of specialization
on social and environment statistics, population and health etc. The functions of
the NSC among others also include evolving standard statistical methodologies
and strategies for data collection of core statistics. Therefore the issue of carrying
out the Annual Health Survey, including the development of methodologies
should be referred to NSC.
Problems in making estimates - remedial suggestions
10. In India, as brought out elsewhere, the data reporting machinery under the RED
Act does not capture all the births and deaths, except those that occur in Health
Institutions. Further, the social aversion towards performing autopsy, except per
force in medico-legal cases, makes the information on causes of death weak and
susceptible to errors. Thus the data reporting system being weak, the causes of
death, as ascertained from the official records also fail to be flawless and the
position is dismal for deaths occurring in private health institutions and for deaths
at home.
7
In view of the incomplete coverage from the data reporting system under the Civil
Registration System (CRS) and the inadequacies of the Sample Registration
System (SRS) in terms of its coverage and scope, it is necessary to explore the
feasibility of capturing this information through periodic surveys till such time the
CRS can be strengthened.
11. Village Health Surveys
The Implementation Frame work approved by the Union Cabinet includes a
proposal for having periodic village level (Health) household surveys to be
conducted by ASHA (Accredited Social Health Activist) the Community Worker
with the support
of village Health & Sanitation Committee. If this can be
strengthened it would provide for a system of reporting & collection of data at the
village level, facilitate development of village block & District Level Health
Action Plans under NRHM.
12. Suggestions : The Working Group made the following suggestions in this
regard:Improve the record keeping system in hospitals and health institutions (both
public and private) by specifying mandatory records and registers to be
maintained and regularly updated, inter-alia specify formats and periodicity of
statutory returns. The steps involved in this would include:
Amendment of RED Act - to make registration of births and deaths mandatory
while also making it more citizen-friendly. Using Health Workers as a medium
for providing information on incidence of births and deaths; and as a medium for
delivery of birth and death certificates as an outreach activity. This would aim to
improve the coverage of the CRS and SRS. However, it may not be able to
capture the detailed cause of death vis-a-vis the ICD-10.
•
Computerization of births and deaths including making the process on-line/web-
based through e-govemance initiatives.
•
Promulgate a Health Information Act that would make it mandatory for registered
Health Institutions and medical practitioners, both Private and Public, to provide
8
periodic information on specified returns. This aims to capture information from
births and deaths that are attended to in registered institutions and by medical
practitioners.
•
The States prepare an Eligible Couple Register (ECR) for the Health and Family
Welfare interventions on the basis of a household survey in the villages
undertaken by the Health Workers (ANMs etc). While some States update the
ECR each year, the position varies in other States. However, as the record keeping
process of the household survey is by and large manual, it is susceptible to the
errors of manual updation including omissions and duplication. Some States like
Andhra Pradesh have undertaken a Household Survey and have given unique FW
numbers to each household, which is updated each year and the ECR is
computerised at the PHC level. If expanded, this could form the frame for
tracking births and deaths that could then be followed up by focussed surveys.
•
Strengthen the Monitoring of Information and Evaluation System (MIES) for
NRHM and to explore the possibilities of enacting a Health Information Act.
•
Concurrent Monitoring through Medical Colleges. The State of Uttar Pradesh has
piloted a scheme of concurrent monitoring and evaluation through the Medical
Colleges. This protocols developed under this pilot could be used as a model for
evolving an independent mechanism to monitor the RCH indicators along with the
causes of death [ see Annex-Ill for a more detailed description].
*****
9
CHAPTER-3
REVIEW OF MAJOR
PROGRAMMES
REPRODUCTIVE
AND
CHILD
HEALTH
RCH Project, Phase-I
1
The first phase of Reproductive and Child Health (RCH) Programme was
launched in 1997 by integrating all on-going fertility regulation and maternal and
child health schemes of the Ministry under a single umbrella, adopting a holistic
target free approach1.
The specific objectives for the RCH I project were set as assisting the National
Family Welfare Programme (NFWP) to:(a) improve management performance by nationwide implementation of policy
change referred to as the "participatory planning approach,'" and institutional
strengthening for timely, coordinated utilization of project resources;
(b) improve quality, coverage and effectiveness of existing FW services;
(c) progressively expand the scope and content of existing FW services to include
more elements of a defined package of essential reproductive and child health
(RCH) services; and
(d) in selected disadvantaged districts and cities, increase access by strengthening
FW infrastructure while improving its quality.
Impact ofRCH-I: An assessment
2
Conceptually, RCH-I was designed to promote decentralization and offer a broad
based financial envelope to the States. However, the project came to represent a
stream of schemes, each having its own norms and reporting requirements, which
called for very strong capacities in the Directorates of Health & Family Welfare in
the States. Since the States’ capacities varied, the results have not been uniform
(Table-3.1). The following weaknesses were identified in the program :
•
There was limited involvement of States in designing the Project and,
therefore, limited ownership of the programme by the States.
•
The pace of implementation was slow.
1 Adoption of the so-called Target Free Approach, which was positioned as the ‘USP’ of the Programme,
actually meant to re-orient the fertility regulation interventions so that the services are rendered according
to the clients’ choice. This was the central theme under lying the Community Needs Assessment Approach.
10
•
Low utilization of public health facilities.
•
Infrastructure (that was planned) was not completed within the project
timeframe.
•
Limited management capacity at various levels.
•
Weak financial management systems.
•
Project lacked vision and policy guidelines.
•
RCH-I was implemented as a project; there was a need to incorporate well
defined outcome indicators.
•
RCH-I had a “one size fits all” design.
•
RCH-I suffered from “stand alone” project approach with little focus on sector
management and reform and strengthening of systems.
•
RCH-I focused almost exclusively on the supply side.
Table-3.1: Targets and achievements under RCH-I (selected indicators)
Target
Actual
I
Impact /outcome Indicator Base line estimate
estimate
74 (SRS, 1995)
Infant Mortality Rate
Contraceptive Prevalence 47.7%
Rate
(RHS-I, 1998-99)
Institutional Deliveries
35%
(RHS-I, 98-99)
% of children fully 52%
(RHS-I, 98-99)
immunized
Unmet needs for family 19.5%
planning services [% of (RHS-I, 98-99)
couples wanting to limit or
space but not currently
using any FP method]
3
60
60%
60%
60%
latest
63 (SRS, 2002)
52%
(RHS-II, 2002-03)
40%
(RHS-II, 2002-03)
44.6%
(RHS-II, 2002-03)
Less than 15.9%
(RHS-II, 2002-03)
10%
One of the key goals of the project was to reduce the disparities in RCH between
the regions, socio-economic groups, etc. However, comparison of RHS data for
BAG states2 for both the rounds of Rapid Household Surveys indicate no
reduction in disparities in RCH status (3.2). Home visit by outreach workers have
declined everywhere but more sharply in rest of the country than the BAG states.
2
Bihar, Chhatisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh, Uttaranchal
11
Table-3.2: Comparison of EAG States with All India Performance
RHS IIA
RHS I
Gap (India - EAG)
2002-03____
1998-99
India EAG
India
EAG
Indicator
1998-99 2002-03
(%)
(%)
(%)
(%)
any
CPR
7.6
49.0 41.4
11.0
48.6
33.7
method
-3.3
-6.0
18.6 21.9
31.6
Unmet Need
25.3
11.7
8.4
13.7
20.1
31.8
18.1
Full ANC
22.8
14.3
24.1
19.7
46.9
34.0
Instl. Delivery
22.7
13.5
62.1 39.4
40.2
Safe Delivery
26.7
Full
12.4
12.9
49.5 36.6
54.2
41.8
Immunization
5.0
1.7
6.4
4.7
14.8
9.8
Home visit*
A Based on 50 % of districts covered in Phase I of Round II
* Any Health Worker during 3 months prior to survey
Sector Investment Programme
4
In 1997, Gol and European Commission signed a Financing Agreement for
channeling latter’s financial and technical assistance to the National Family
Welfare Programme. Called the Sector Investment Programme (SIP), the
objectives of the partnership was to promote systems development and sector
reforms. Under the original Financing Agreement, a grant assistance of 200
million Euros was pledged over a 5-year period. Following a devastating
earthquake in Gujurat (January, 2001), the Financing Agreement was amended to
provide for an additional amount of Euro 40 million to support the post
earthquake re-construction / re-development work in the State. The programme
period has also been amended (current end date of the Financing Agreement is
December, 2006).
5
The SIP began with implementation of State and district plans in the 11
participating States. Over time, more States joined taking the number of
participating States to 22 consisting of the 8 most backward States (termed EAG
States)3, 8 North-Eastern States and the States of Andhra Pradesh, Gujarat,
Haryana, Himachal Pradesh, Kerala and Maharashtra.
3 The GOI had set up an Empowered Action Group (EAG) in year 2000 for focussed attention to improve
population stabilization issues in the States of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa,
Rajasthan, Uttar Pradesh and Uttaranchal. These States are, therefore, collectively referred to as EAG
States.
12
6
A major weakness of the programme design was that while the overall EC
contribution to GOI was known, the programme coverage was not pre-defined in
geographical terms, either in terms of the number of States or, within a State, in
terms of districts. As a result, while the planning process was emphasising more
efficient use of existing resources, the districts and States were appearing to focus
on maximising their share under the programme. This led the MoHFW to
introduce the so called MoU based financing of sector development activities in
the States. Introduction of the MoU mechanism was adopted from a similar
concept introduced by the Planning Commission4 and consisted of following
features:
•
A pre-announced allocation of funding, taking due account of the degree of
backwardness of the state. Thus, 50% of the remaining programme funding at the
date of introduction of the system (end of March 2002) was ear-marked for the
BAG states, 10% for the north-eastern states, 10% for national activities and 30%
for the non-EAG states admitted to the programme;
•
A mutually agreed health sector reform agenda. A series of milestones (often
consisting of 2 or more sub-milestones) were agreed which would indicate the
degree of progress towards implementation;
•
An agreed spending plan for the allocation. The valuation of the milestones was
calculated on the basis of a rough estimate of the implementation cost of the
state’s proposed reform agenda as well as other expenditure purposes.
•
Advance but performance based funding. Estimated requirement of funds was
released upon MoU execution. However, subsequent releases required, besides
achievement of agreed milestones, minimum 50% utilization of previous
releases.
7
The key elements of the reform processes formalised under the MoUs were drawn
from the national level policy documents such as 9th / 10th Five Year Plan,
National Population Policy (2000), National Health Policy (2002) etc. and
included, among others, the following:
•
re-structuring /re-organisation of primary health care delivery infrastructure,
•
strengthening of planning and programming skills,
•
decentralisation,
4 Rashtriya Sam Vika Yojana.
13
LUuK F
•
community participation, including establishment of autonomous hospital
management societies (Rogi Kalyan Samitis or equivalent) and involvement of
Panchayati Raj Institutions (PRI)
improved logistics and warehousing of drugs and medical supplies,
•
strengthening of secondary hospitals for improved access to basic health care
•
services, including emergency services,
•
horizontal integration of vertical structures,
•
human resource development through cadre re-structuring, multi-skilling,
development of training / transfer policy
re-structuring and strengthening of health management information systems,
•
A total of 15 MoUs were executed between June, 2003 and February, 20055. The
financial performance under the programme has witnessed an acceleration in
funds disbursement and utilization after the introduction of the MoU mechanism.
The final evaluation of the programme, conducted in July, 2006, has highlighted
the use of MoU as a key ‘driver’ of programme. Facilitation by an independent
technical assistance team has been cited as another contributing factor6.
RCH-II
8. Planning process for RCH-II started in year 2002 with a detailed consultation
process involving the States, Development Partners, the civil society and other
stakeholders.
The main issues identified during the consultation / preparation processes have
been responded to through the design of RCH-II which represents the mid-course
correction in the 10th Plan. The specific issues identified during mid-term review
I consultations and the measures to address the same under the RCH-II are listed
in Annex- IV.
The vision underlying RCH-II is to bring about outcomes as envisioned in the
Millennium Development Goals, the National Population Policy 2000 (NPP
2000), the Tenth Plan document, the National Health Policy 2002 and Vision
5 Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Haryana, Himachal Pradesh, Jharkhand, MP,
Maharashtra, Orissa, Rajasthan, UP, Uttaranchal and West Bengal. Remaining 9 States were allowed to
continue with their existing State plans.
6 European Commission Technical Assistance (ECTA) consists of a full time team located at New Delhi,
another full time team based at Gandhinagar to assist the post-earthquake re-construction work in Gujarat
and ECTA State Facilitators in Assam, Bihar, MP, Rajasthan, UP and Uttaranchal.
14
2020 India, minimizing the regional variations in the areas of reproductive and
child health and population stabilization through an integrated, focused,
participatory program, meeting the unmet demands of the target population and
provision of assured, equitable, responsive quality services.
Table-3.3: RCH-II goals vis-a-vis MDGs, NPP and 10th Plan
Tenth
Plan RCH
Indicator
(2002-2007)
16.2%
(2001-11)
________
16.2%
(2001-11)
45/1000
35/1000
___________
Population
growth_______
Infant
Mortality Rate
Phase
Policy 2000
(By 2010)
Reduce by 2/3
from
1990
levels
Maternal
Mortality
200/100000
Ratio_________
Rate_________
Couple
Protection
Rate
_______________
<30/1000
Under
5
Mortality Rate
Total Fertility
Millennium
Mil
Development
Goals
150/100000
<100/100000
2.3
2.1
2.1
65%
65%
Meet 100% needs
Reduce by %
by 2015
The principles underlying the design of RCH-II are as follows:
•
Improving health outcomes is a shared responsibility of providers, local
governments, households and communities.
•
There should be no discrimination in access to essential quality health services.
•
The poorest have the right to get value for money being spent by government or
out of pocket.
•
Service providers should be responsible for outputs and outcomes, suitably
empowered, and made accountable within the principle of subsidiary.
•
Female children have an equal right to health, emergency medical aid, and to live
with human dignity.
•
The program would include voluntary and informed choice in administering
family planning services. Responsibilities of service providers would be clearly
outlined with careful regard for human resources. Clear tasks would be laid out
for service providers to provide quality services to meet unmet needs of family
planning and spacing methods in desirable quantities.
15
•
The strengths of public and private sectors should be harnessed to achieve the
RCH program goals.
•
The RCH program will protect people in accordance with the statutes.
•
The RCH program efforts will consistently focus on the most vulnerable.
9. The RCH-II also represents another step towards adoption of the so-called Sector
Wide Approach(SWAp), a process that began with Sector Investment Programme
and taken further along under the NRHM. The ‘sector’ level policies articulated
under national Programme Implementation Plan (PIP) have been subsumed and
further refined under the NRHM.
Box-3.1: ‘Sector’ level policies governing RCH-II design and
implementation
•
•
•
•
•
•
•
•
Bring about inter-sectoral collaboration through networking at the highest
levels and then percolating to the different levels.
To include public health as a specialization into the medical education
curriculum in order to bring out trained public health managers to
manage the public health and bringing in public health as a function.
To revitalize the human resources policy such as district cadres of MOs
and block cadres of ANMs and also address the career movement,
posting and training issues.
Open up primary health care to groups of professionals/individuals
willing to take on such service provision functions especially at the
primary levels accompanied by appropriate governance mechanisms.
Activating voluntary level societies/ community level workers for
bringing in additional funds into the sector (ZSS, RKS+ JSK, ASHA)
Address adolescent health as an important issue and develop packages for
activating this aspect.
Integrate with the on going National AIDS Control Program (NACP) and
establish linkages with HIV prevention programs.
Develop separate plans for dealing with the problems of vulnerable
groups including a tribal action plan and an action plan for the urban
poor.
10. The RCH-II is being implemented through State Programme Implementation
Plans (PIPs) prepared within broad parameters of national PIP, allowing the States
the freedom to choose their own programmatic / management interventions for the
16
national objective of reducing TFR, IMR and MMR. Funding of the State PIPs is
done through Annual Work Plans.
11. The Technical Strategies and interventions relating to Reproductive, Maternal and
Child Health envisaged under RCH-II programme are detailed at Annex-V.
12. In keeping with the SWAp principles, the programme will be jointly evaluated by
the MoHFW, Development Partners and the State Governments on a six-monthly
basis. The second Joint Review is scheduled to be completed in mid-October,
2006)7.
Promoting Institutional delivery
13. Encouraging the pregnant women to deliver in heath centers /institutions has been
one of the core strategies for reducing infant and maternal mortality. At the
national level, institutional delivery rate prior to the RCH Phase I, as per the
NFHS-II (1998-99) was only around 33.6 %. Several new initiatives were taken
during RCH-I for improving safe motherhood. The rate of institutional deliveries
as per the DHS-II (2002-04) was only 41.5 %. Inter state variations and variations
among the different income groups have been quite significant. Though, results of
12 states as per the NFHS-III (at Annexure- IX) conducted in 2005-06 are
showing an increasing trend too, a large number of women, especially from the
poor families living in the weak states still deliver at home. Even among the
weaker states, there is significant differential in institutional deliveries between
rural and urban areas.
14. The NPP goal aims to achieve overall 80 % institutional deliveries by 2010. The
NRHM envisages reducing the MMR and IMR to 100 per 100,000 live births and
30 per 1000 live births by 2012, respectively.
15. As a strategy to change the behavior of the community to access heath institutions
for delivery, the Ministry has modified the National Maternity Benefit Scheme
7 The First Joint Review took place in February, 2006.
17
(NMBS), from that of nutrition improving initiative to that of addressing the
entire aspect of maternal health.
JANANI SURAKSHA YOJANA (JSY) - under the XI Five Year Plan (2007-2012)
16. The Hon’ble Prime Minister launched Janani Suraksha Yojana (JSY) on 12th
April 2005. The scheme has the dual objectives of reducing maternal and infant
mortality by promoting institutional delivery among the poor women.
17. Though the JSY is implemented in all States and UTs, focuses especially in states
having low institutional delivery rate. In states where the institutional delivery
rate is abysmally low, namely in the states of Uttar Pradesh, Uttaranchal, Bihar,
Jharkhand, Madhya Pradesh, Chhattisgarh, Assam and Jammu and Kashmir have
been categorized as Low Performing States (EPS). The remaining states have
been named as High performing States (HPS). The institutional delivery rates in
key States is given at Annexure VI.
18. The scheme is a 100 % centrally sponsored and integrates cash assistance with
maternal care. It is funded through the RCH flexi-pool mechanism. The JSY
scheme targets •
•
•
All pregnant women in the low performing States (EPS).
All BPL pregnant women of age 19 years or above, in High performing
states (HPS)
All ST and ST pregnant women from both EPS & HPS states,
19. Scale of Cash Assistance per delivery:
Category
EPS
HPS
•
Rural Area
Mother’s ASHA’s
Package Package
1400
600
700
Total
Rs.
2000
700
Urban Area
Mother’s ASHA’s
Package Package
200
1000
600
Total
Rs.
1200
600
In EPS states: Mother’s package is available to all women including all SC and
ST women, delivering in any public or accredited private institutions. No age or
18
•
•
BPL certification would be insisted upon. Similarly, restriction on number of
childbirths has also been removed.
In HPS states: Mother’s package is available to all BPL pregnant women
including all SC and ST women, aged 19 years and above, up to 2 births,
delivering in any public or accredited private institutions.
In addition, all BPL pregnant women aged 19 years or above preferring to
deliver at home will receive cash assistance @Rs.500/- per delivery, up to 2 live
births.
20 ASHA package available in EPS and NE states consists of transport assistance to
the mother and compensation assistance to the ASHA in the rural areas. In the
urban areas, the money is only for ASHA to meet her transactional cost of
accompanying the pregnant women for delivery. In addition, the scheme has
other benefits:
(a) If hospitalization for delivery is followed immediately by Tubectomy /
laparoscopy, the beneficiary would get compensation money available under the
existing Family welfare scheme at the hospital itself.
(b) Where Government specialists are not available in the Govt’s health
institution, for managing complications, assistance up to Rs. 1500/- per case is
being given to the health institution for hiring services of experts in a
Government medical facility. If a private medical expert is not available, expert
doctors working in the other Government set-ups may even be empanelled,
provided his/her services are spare.
21. Under the Tenth plan, a sum of Rs. 500.00 crores was allocated for NMBS of
which around Rs.212.00 crores was released to the states. It is anticipated that
around Rs.200.00 crores would be expended this year. Due to the recent
modifications approved by the Mission Steering Group in the meeting held on
22.9.2006, the estimated cost of implementation, as per the existing parameters is
anticipated as follows:
Estimated
Requirement of
fund (In crores)
2007- 08
250.00_________
2008- 09
300.00_________
2009- 10
350.00_________
2010-2011
400.00_________
2011- 12
450.00__________
Total
1750.00
Reivew of the Universal Immunization Programme. (UIP)
Year
19
X Plan
Immunization Programme in India was introduced in 1978 as Expanded Programme on
Immunization with limited reach mostly in urban area. The programme was universalized
in 1985-86 to cover six vaccine preventable diseases under Universal Immunization
Programme in phased manner and covered all districts in the country by 1989-90. The
reported coverage data from 1990 to 2005-06 is at Annexure VII. In 1986, the
programme became part of the Technology Mission and monitored under 20 point
programme by Prime Minister’s Office. From 1992, the programme formed a part of the
CSSM programme and subsequently under RCH programme from 1997.
The district level survey conducted in 2002-04 (Annexure-VIII) indicated that the
immunization coverage has decline in the country when compared to 1998-99 district
level survey. This decline has been more pronounced in the EAG States, NE States.
Under the NRHM immunization has been the thrust areas and more focus has been given
to improve the coverage. Some of the intervention carried out for the first time to
improve coverage are as under
Introduction of AD syringe : In the immunization programme glass syringes were used
after sterilization for injection. The INCLEN study revealed that 17% of the injections
were due to immunization and 2/3 of the injections given were unsafe. In order to address
to injection safety and increase efficiency in the programme the Ministry of Health and
Family Welfare introduced Auto Disable (AD) syringe in the immunization programme
in the last quarter of 2005. The AD syringe is now been universally available for use in
the immunization programme across the country.
The Multi year plan is the basis for strengthened routine immunization. Under this plan
the States have made their State specific project implementation plan (PIP) ie PIP part-C
of NRHM. The PIPs covers area for strengthening the Service delivery component of
Routine immunization. These are:
i.
Alternate vaccine delivery: The last storage point of vaccine is PHC. For this
purpose every PHC and above has been provided with twin set of Ice Line
Refrigerator (ILR) and Deep Freezer (DF). Every district has been provided with
one vaccine van. The vaccine is being transported from the State HQ to PHC with
the help of these vaccines Van. However, there was no support for transportation
of vaccine from PHC to village session site, as a result ANM used to collect and
transport vaccine to session site thereby consuming lot of valuable time which
otherwise could have been use for conducting immunization session. In order to
bring in efficiency and fidelity to the program, support has been provided to
deliver the vaccine in the village and other outreach session site as per microplan.
The flexibility has been provided to use the available local means of transport.
However, there has to be appropriate maintenance of record for transparency.
ii.
Alternate Vaccinators: It was observe that most of the plan sessions are not held
as the vaccinator is not available. In order to ensure that every plan session as per
microplan is held, a provision has been made for alternate vaccinators who are not
20
part of the system by providing honorarium @ Rs 350 per session conducted.
Therefore, such session will be conducted either at Urban Slum, Un-served or
under-served areas. In order to operationalised the alternate vaccinator each
district should have list of such vaccinator prepared well in advance so that these
worker could be pressed for conducting sessions at the short notice.
iii.
Social Mobilization : Social mobilization of beneficiaries by the ASHA
(Accredited Social Health Activist) / Link Worker / Aanganwari worker (AWW) /
local RI mobilizer etc is one of the important activity to improve coverage. The
social mobiliser should be assign specific task of mobilising (i) all children who
dropped out the last session. For this purpose ANM will prepare list of defaulter
using Tickler boxes/bags/other methods and hand over one copy to the
mobililiser. (ii) Social mobiliser to prepare a list of all new bom delivered in
between two sessions mobilised them for vaccination, (iii) Besides this she would
also inform all other beneficiaries the next date of vaccination and mobilised
them. For this purpose ASHA or link worker is provided Rs 150 per session in
ASHA State and Rs 100 in non ASHA state.
iv.
Strengthening Supportive supervision : Each district has been provided a sum
of Rs 50,000 for mobility support to carryout supportive supervision. In bigger
State a sum of Rs 1,00,000 has been provided at the State level for the mobility
support of the State officials for supporteive supervision. Each such visit should
be followed by a written report of the visit and feedback to all other sessions on
the observations.
v.
Half yearly meeting at State with districts : Support has been provided for
organisiting half yearly meeting with district officials at the State. A central
government representative must be invited in such meeting.
vi.
Support for POL : In order to run genset some State has been provided support
of POL.
vii.
Printing : Printing of Immunization card, Immunization register, temperature
chart, tickler box etc must be carried out by the State. There will be no further
supply from the center. However, to maintain universality of these immunization
cards, immunization register, State will stick the design and format of the center.
viii.
Downsizing BCG vaccine vial: The BCG vaccine vial has been down sized from
20 dose to 10 dose to ensure that the vaccine is available in every session site.
ix.
Computer assistant : for e-reporting and e-monitoring
x.
Miscellaneous Support for POL etc to run gen-set for maintenance of cold chain
Hepatitis B vaccination : The Hepatiotis B vaccine has been introduced as a pilot project
in 33 district and 15 cities with support from GAVE With the successful implementation
of the pilot project in has been decided to expand the Hepatitis B vaccination in the 11
21
good performing States were the evaluated coverage of DTP 3rd dose is more than 80%
with plans to expand in the remaining States.
Japanese Encephalitis (JE) vaccination : JE vaccination using SA-14-14-2 vaccine has
been carried out in the 11 high risk district covering children between 1 to 15 years of age
starting from May 2006 and approximalely 9.03 million children received JE vaccine
during this campaign. It is planned to cover the remaining high risk district in phase
manner.
SURVEILLANCE OF VACCINE PREVENTABLE DISEASES
Although reporting of VPDs is a component of the CNAA reporting format, the
Department of Family Welfare has to resort to the data made available by CBHI since the
CNAA reporting is neither regular nor complete.
In order to further strengthen the VPD surveillance certain new initiatives have
been taken.
Measles Surveillance has been integrated with the existing AFP surveillance in
three states of Tamil Nadu, Karnataka and Andhara Pradesh and there are plans to
expansion to other States.
Neonatal tetanus (NT) elimination
NT is a global goal; elimination is defined as an annual rate of less than 1 case of NT per
1000 live births in every district in the country.
The Government of India (GOI), Universal Immunization Program (UIP) is planning to
demonstrate elimination of Maternal & Neonatal Tetanus in the country by 2009. Already
in seven States (Andhra Pradesh, Kerala, Tamil Nadu, Karnataka, Maharashtra, Haryana,
and West Bengal) this validation exercise has been carried out. It is planned to validate
the remaining States in the next three year. For this purpose 6 to 7 states are identified
each year. The Union Territories and smaller states will be clubbed for validation
purpose.
The validation process involves collection of district wise data for the last three year for
TT pregnant women coverage, Institutional delivery rate, NNT cases etc. The said data is
used for identification of worst performing district where chances of finding NNT higher
compared to other district. The identified district is then surveyed for Lot Quality
Assessment Cluster Sampling surveys (LQA-CS.) Through LQA all death of IMR are
subjected to verbal autopsy for identification ofNNT death.
Recommendations after validation ofNNT elimination;
(i)
(ii)
(iii)
maintaining high TT vaccination coverage to pregnant women,
improve institutional delivery practices
Strengthen surveillance ofNNT.
Polio Eradication Programme:
22
10th Plan Period
During the 10th plan period remarkable progress has been made in controlling the
transmission of polio virus in India. Compared to 1600 cases detected in year 2002, only
66 cases were reported in 2005 throughout the country. The geographical spread also
declined from 159 districts in 2002 to 35 districts in year 2005. Of the three main types of
virus causing polio, type 2 was eliminated in 1999 (with the last case identified in
western Uttar Pradesh). The type 3 virus is only circulating in Moradabad district of UP.
The type 1 polio virus, the main cause of disease in India, had been eliminated from all
but parts of two states - western Uttar Pradesh, and northern Bihar. Of the 14 genetic
families of type 1 virus circulating in 2002, 12 genetic families have become extinct and
only 2 are in circulation.
This year has seen an outbreak of disease in Moradabad, western UP which now threatens
the substantial gains made over the last few years. Data on the pulse polio vaccination
campaign coverage showed that in late 2005 and early 2006, increased numbers of
children did not receive the polio vaccine. This gave an opportunity to the polio virus to
maintain its circulation and infect and paralyse the susceptible children This polio virus
from UP has now re-infected other districts in UP and other states which had previously
eliminated the polio virus circulation. During this year so far 352 cases have been
reported from the country out of which 312 are from UP, 20 from Bihar, 5 each from
Haryana and Uttaranchal, 2 each from MP and Maharashtra and one each from Delhi,
Chandigarh, Punjab, Gujarat, Jharkhand and West Bengal.
A new scheme of corrective surgery and rehabilitation of polio affected children was
approved for undertaking corrective surgery of 20,000 affected children in the age group
of 3-18 years during 2006-07 and 2007-08 as pilot for which a provision of Rs.20cr. have
been made. A scheme for its implementation has already been prepared by a committee
under the Chairmanship of Additional Director General Health Services. The same has
also been examined by the IFD and concurred. The scheme is being disseminated
initially to the States having high incidences of polio in the past for undertaking
corrective surgery at the district / state hospitals by involving NGOs already in the for
mobilization and other supports. Funds for this scheme will be routed through State
Health Societies under NRHM.
11th Plan Period:
The current strategy of pulse Polio Programme of vaccinating the children between 0-5
years of age during NID and SNIDs will be implemented during the 11th Plan period to
achieve zero transmission and obtaining polio free certification. To get certification, the
country will sustain the zero transmission status for consecutive three years.
The Scheme of corrective surgery may also be undertaken during 11th plan period to
provide facility of corrective surgery to cover the remaining polio affected children in
the age group of 3-18 years.
23
XI Plan
•
•
•
•
Continuation of the existing programme
Continue expansion of Hepatitis B vaccine in the country
Phase expansion of JE vaccination to high risk districts
Introduction of newer vaccine in the immunization programme based on disease
burden or recommendation by the experts.
Interventions under the NRHM
The Implementation Frame Work under NRHM (Annexure II) as approved by the
Union Cabinet takes a holistic view of Primary Health Care in the country especially
in relation to its goals of reduction of IMR, MMR and TFR. The
infrastructure/logistical support for providing drugs and equipments and availability
of manpowers requirements, for making facilities fully functional, leading to service
guarantees and clear health outcomes have been fully taken care of under the Mission.
However, some of the additional issues as noted above need to be fully addressed to
improve the health status of women and children under the Five Year Plan.
*********
24
CHAPTER-4
REVIEW OF THE FUNCTIONING OF THE FAMILY WELFARE
INFRASTRUCTURE.
State of Public Sector Service Infrastructure
1. When the Family Welfare Programme was initiated in the early 1970s, the
infrastructure for providing maternal and child health and family planning
services was inadequate at the primary health care level, and sub-optimal in the
secondary and tertiary care levels. In order to quickly improve the situation, the
Department of Family Welfare, Government of India created and funded post
partum centres, urban family welfare centers/health posts and provided additional
staff to the then existing block level facilities (usually block PHCs). In addition,
the posts of ANMs in the sub centres, created after the initiation of the Family
Welfare Programme, were also funded by the Department. The Department of
Family Welfare also created state and district level infrastructure for carrying out
the programmes and setting up training institutions for pre/in-service training of
personnel. All these activities were being funded through Plan funds.
2. Over the last three decades, there has been considerable expansion and
strengthening of the health care infrastructure by the States. Family welfare
services are now an integral part of services provided by primary, secondary and
tertiary care institutions. The staff funded by the Department of Family Welfare
under the scheme of rural family welfare centres and post partum centers are state
health services personnel functioning as part of the state infrastructure. In view of
this, the Ninth Plan recommended that the funding should be taken over by the
state Department of Health. States have since taken over the responsibility of
funding post-partum centers and rural family welfare centers from 1 April
2OO2.The fact remains, however, that service delivery network remains extremely
weak both in terms of physical infrastructure as well as human resources.
Resource mismatch makes the matters worse: specialists are posted to a facility
not meant / equipped to provide specialist services and vice versa8.
8 Planning Commission report on Evaluation ofFunctioning of Community Health Centres.
25
3. Although 8th, 9th and 10th Plans have been emphasizing that infrastructure
planning requires equal emphasis on reorganizing / re-structuring various types
and kinds of health facilities, most planning exercises by the States have treated
the primary health care infrastructure to consist only of Sub-centres, Primary
Health Centres and Community Health Centres; ISM dispensaries and hospitals
and the public health facilities outside the administrative control of the health
department are most often than not ignored.
4. There have been two large scale facility surveys during RCH-I period, both
conducted by International Institute of Population Sciences, Bombay. The first
survey was conducted in 1999 covering 221 districts, followed by another survey
in 2003 covering the remaining 370 districts.
5. The findings of the first facility survey (1999), covering 210 district hospitals, 760
FRUs, 866 CHCs and 7,959 PHCs indicated acute shortage /inadequacy of basic
physical infrastructure at the PHC and CHC levels (Table 4.1).
4.1: Summary of findings of the facility survey 1999__________
Availability
Availability Availability
SI.
FACILITY
in PHC
inFRU
No. _ __________________
to
92%
96%
Own buildings_____________ 98%
_L
86%
2^ OT__________ ____________ 93%
28%
28%
Labor room________________ 36%
_3.
_*
71%
Over head water storage tank 82%
4.
& pump___________________
9%
Blood bank / BSF / Linkage 17%
5.
with D BB_________________
52%
Diesel Generator___________ 71%
6.
20%
62%
Telephone_________________ 80%
7.
2%
Computers________________ 2%
8.
29%
73%
61%
Functional vehicle
9.
*62 % of the PHCs surveyed are having water supply facility only but not having
storage tanks & pumps, etc.
6. The 2003 survey, which covered a much larger number of facilities, including the
AYUSH facilities9, confirmed the findings of the first survey (Tables 4.2, 4.3 and
9 Survey covered 370 district hospitals, 1882 First Referral Units, 1625 CHCs, 9688 PHCs, 18385 Sub
centres, 2151 AYUSH Hospitals and 7064 AYUSH dispensaries.
26
4.4). However, the second survey also revealed the huge latent potential for
improved access through reorganizing /re-structuring exercise (Table 4.5).
Table 4.2: Functional adequacy of District Hospitals, FRUs and CHCs
CHC
District
FRU
Hospital
Proportion (%) of facilities having....
44.4
Separate aseptic labor
room__________________________
Telephone facility________________ 96.7
OPD
facility
for
56.4
RTI/STI_______
Linkage with district
67.5
blood bank___________
60.5
Regular blood supply
Quarters for obstetrician
40.1
/ gynecologist
Facility adequately equipped in terms of...
93.0
Infrastructure @______
80.0
Medical Staff @@
32.0
Paramedical Staff (*)
45.0
Supply(**)___________
84.0
Equipment #__________
Referred delivery cases
37.0
attended during last
three months ##
33.3
31.0
74.8
24.9
62.2
16.0
27.2
15.8
27.7
28.5
10.5
21.0
76.0
37.0
37.0
32.0
61.0
63.0
14.0
41.0
24.0
46.0
39.0
46.0
@
Overhead tank and pump facility, electricity in all parts of the hospital,
availability of generator, telephone, functional vehicle, laboratory, operation theatre,
separate aseptic labour room
@@ Includes obstetrician / gynecologist, pediatrician and anesthetist.
(*)Include staff nurse, ANM, pharmacist, laboratory technician, PHN, health
assistant male and female.
(**)Includes tubal ring, set of standard surgical kits, emergency obstetric care
kit, new bom care kit, RTI/STI kits and delivery kit 1
# Includes Boyle’s apparatus, shadow-less lamp and oxygen cylinder.
## Calculated from the number of health facilities which have conducted
delivery.
27
______ Table 4.3: Proportion of Primary Health Centres adequately equipped
Proportion (%) of PHCs having
89.2
48.4
19.8
52.0
Own building_____
Labour room______
Telephone________
Staff quarter for MO
Proportion (%) of PHCs adequately equipped (at least 60%) in terms of
31.8
Infrastructure @_____________________________________________
48.2
Staff @@___________________________________________________
39.9
Supply $___________________________________________________
41.3
Equipment $$_______________________________________________
_Training
___________________________________
19.9
#
@ Includes tap water, regular supply of water, electricity, telephone, toilet, functional
vehicle and Labour room available
@@ Includes Medical officers male, female and paramedical staff
$ Includes IUD kits, delivery kits, mounted lamp supply of OP, measles, IFA large and
ORS
$$ Includes deep freezer, BP instrument, autoclave, labour room equipment, MTP
suction and oxygen cylinder
# Includes only medical officers who are currently in position
_______________ Table 4.4: Adequacy of inputs at the Sub-centres
Proportion (%) of Sub-centres having ....________________________
Own (govt) buildings____________________________________ ____
Electricity
45.2
43.2
Health Worker (Female) in position
Health Worker Male in position
95.1
67.7
Paramedical staff trained in IUD insertion
1.2
_________ Table 4.5: Availability of infrastructure under AYUSH network
AYUSH dispensary
AYUSH Hospital
_________Proportion having
______________
30.0
_____________
16.7
Own Building____________
_______
Not
applicable
_____________ 92.8
At least one Bed__________
_____________ 76.8 ______________ 83.2
Medical Officer in Position
_____________ 72.4 ______________ 62.0
Sisters in Position_________
______________ 872
____________ 76.0
Staff Nurse in Position_____
84.4
77.1
Pharmacist in Position
28
7. Following issues emerge from the above data generated through the facility
surveys:
•
•
•
•
A very significant part of the so-called infrastructure shortage - number of
PHCs, number of doctors, nurses and pharmacists can be met through the re
organization exercise. This is particularly so as a large proportion of AYUSH
hospitals / dispensaries and PHCs are operating from rented premises.
Non-availability of asceptic labour rooms and lack of access to safe blood are
the leading barriers to access to emergency services.
Technical skills of providers are extremely weak or inadequate with less than
2% ANMs having received IUD insertion training and less than 20% of PHC
medical officers having received adequate training.
The NRHM initiatives addresses the infrastructure gaps. The associated institutional
reforms [functional autonomy to Rogi Kalyan Samiti] will also contribute to
improving efficiencies. However, the delivery network will remain sub-optimal
unless the investments are preceded by a district specific health infrastructure
development plan based on a resource mapping exercise. This is a specialized task
calling for a steering role for the Ministry of Health & Family Welfare. The working
group noted that facilities surveys have been under taken by the States prior to their
taking up their upgradaion to IPHS. While under the RCH-II all Community Health
Centers in the country are being converted to First Referral Units (FRUs) their
upgration to IPHS has also been taken up under NRHM. IPHS is being finalized by
the task force for PHCs and Sub-centers. The Implementation Framework of NRHM
approved by the Union Cabinet fully takes the entire infrastructure issues under
consideration. A few States [e.g. UP and Chhattisgarh] have developed GIS based
tools which can be used for this exercise.
8. Public - Private Partnerships : Issues and options
Public - Private Partnerships can be used as an effective instrument for achieving
public health goals and a number of initiatives have been introduced by the States
with positive results. Some recent examples are:
• Establishment of diagnostic services and CT-scan units in West Bengal;
positive results led the State to expand the arrangement to rural hospitals /
block PHCs in the year 2004.
• Management of 133 ambulances by NGOs for emergency transport in rural
areas of West Bengal.
• Outsourcing of ambulance services, diet, laundry, cleaning, installation and
management of X-ray /pathology services in Bihar
29
•
•
Contracting-out of PHCs in Arunachal Pradesh, Bihar, Karnataka and Gujarat
The “Chiranjivi” scheme in Gujarat for delivery care of BPL women.
While efforts to strengthen and optimize existing public facilities with more
investment and better management should receive priority, collaborating with
non-govemment stake holders will still be required due to the Governments’
limitations in mobilizing the required capital for meeting the growing demand and
more importantly, the expertise and skill base that the private sector attracts.
Collaboration must, however, be funded on a regulatory framework and insurance
system licensed by the Gol to ensure that there is no adverse selection and risk
sharing is facilitated.
Evidence and good practice from several developed countries show that protocols
exist that can be usefully adopted and adapted to address quality and
appropriateness of care, measurable against volumes delivered at different levels
of the system from hospital to outpatient and ambulatory care. The single most
effective way of managing the sector and speeding the restructuring process of
provider markets is though standards and treatment protocols and having a system
for enforcing them. Standard-based payment systems help in enforcing provider
accountability and also check unethical practices and conflicts of interest.
However, they need intensive and extensive training and capacity building aiming
at deploying controllers and assessors who are conversant with new techniques of
technical and financial audit and evaluation. There is also a need to establish
parameters and system for remuneration of outsourced accredited providers, based
on health accounts that are currently lagging in the health system
9. The Challenge of human resource requirements Health being a human resource
intensive sector, it is imperative that a long term perspective plan is developed
and adopted to ensure that adequately trained and effective health providers are
available in sufficient numbers at all levels. While this issue has been debated in
the past, the distribution of medical colleges, nursing and paramedical training
institutions have come up in different parts of the country without any relationship
with the geographical needs [Annex-IX (a)] development of specialties in
different disciplines have not kept pace with the actual requirement of specialized
services, particularly in public health field and in rural areas. The total annual
intake for specialists related to maternal care, for example, is highly insufficient
[Annex-IX (b)]
30
10. The nursing education sector is characterized by a similar skewed distribution: UP
has only 30 ANM training centres for 70 districts and Bihar only 27 whereas
Andhra Pradesh has 30 ANM training schools, 182 institutions recognized for
GNM course and 107 recognized for B.Sc. Nursing course [Annex-X (a)].
Although there has been a sharp increase in the nursing training institutions in the
last couple of years [Annex-X (b)] indicating number of institutions existing as
on 31st March, 2004), the network will need to be expanded on a much faster rate
to be able to catch up with global doctor-nurse ratio.
11. Nursing Educational Institutions
Independent Nurse Practitioner: The Indian Nursing Council developed a new
nursing course / discipline called the Independent Nurse Practitioner(INP). The
INP course is an 18 month post basic diploma in midwifery10 and imparts all
skills necessary to handle obstetric emergencies (including blood transfusion).
The INP is authorized to and can establish her own, independent practice. The
course has been piloted by INC in West Bengal and 2 of the 4 trainees have been
assigned to a CHC to manage obstetric cases.
The Sri Lanka experience quoted in the 10th Plan MTR indicates that the IPNs,
whose skill levels would be equivalent to that of the Sri Lankan Public Health
Midwife (PHM), would be a more suitable choice for MCH care at the
community level, that is, the Sub-centre. Given the limited training capacity, such
large numbers can not be trained in the immediate future. As such, this option can
not be exercised till the training capacities has been expanded. However, the INP
training must be started in as many places as possible and the States should
consider sponsoring suitable candidates who are willing to establish their private
practice in rural areas. The Hospital Management Societies should also be
encouraged to engage the INPs on the basis of a monthly retainer-ship basis plus
payments linked to cases handled.
12. Following other suggestions are made with regard to Nursing Educational
Institutions:
• A dedicated Nursing and Paramedical Manpower Division / Unit should be
established at the National and State levels.
10 In INC terminology, Diploma in General Nursing and Midwifery (GNM) and B.Sc. Nursing are called
basic nursing course.
31
•
•
•
All medical colleges should be mandated to establish a College of Nursing
offering courses in B.Sc. Nursing, M. Sc. Nursing and Post-Basic Diploma
courses in specialty nursing areas.
All District Hospitals should be mandated to establish a school of nursing
offering ANM and Diploma in General Nursing and Midwifery,
Smaller hospitals in public sector having at least 30 OBG beds should be
encouraged to start ANM training
•
Private sector hospitals having at least 30 OBG beds should also be allowed to
start ANM training programme and the concerned State Government should
allow selected public sector rural facilities for their field training.
13. Deployment of AYUSH practitioners for MCH services: The availability of
AYUSH doctors is far better in the rural areas. The hospital management societies
should be encouraged to engage these personnel for conducting deliveries of the
training in the hospitals. The compensation package should be on similar lines as
that suggested above for the INPs if their midwifery skills can be upgraded
through their attachment to district hospital.
14. Medical Education Institutions
The Ministry under the NRHM had setup a task force on medical education. The
recommendations made by the task force are far reaching. The Ministry needs to
examine them early for the purpose of adopting them to meet the manpower
requirements in the rural areas.
15. A contributing factor for poor access levels in the rural areas is that the States
have not sanctioned sufficient staff / specialist positions for the rural areas. On an
overall basis, for example, the States had sanctioned only 7582 posts of specialists
till September, 2005, as against the requirement of 13384 posts for the 3346
CHCs (1 surgeon, 1 OBG specialist, 1 physician and 1 pediatrician for each
CHC)".
16. The NRHM has adopted a set of revised staffing norms for the Sub-centres, PHCs
and CHCs which will add to the human resource needs in the rural areas. For the
ANM, the requirement has doubled as 2 ANMs have been sanctioned for every
Sub-centres. The Sub-centre will continue to be the critical facility for the
11
Rural Health Statistics, 2006 (Ministry of Health and Family Welfare)
32
delivery of health care of women and children in rural and remote areas where no
other facility exists. The objective of making 2000 facilities as fully functional
FRUs will require at least 2000 specialists in OBG, anesthesia and pediatrics
(each) and 20,000 staff nurses. The objective of making 10,000 PHCs as 24/7
facilities equipped for institutional delivery implies an additional requirement of
30,000 Public Health Nurse Practitioners / General Nurse and Midwives (GNMs).
The NRHM provides for additional manpower at CHC, PHC & Sub-Center levels.
The NRHM provides for additional manpower at CHC, PHC & Sub-Center levels.
A number of strategies and interventions have been proposed to overcome the
shortage of manpower in rural areas including compulsory rural postings using
interns, using NGOs, multi skilling of doctors, pre service training for medical
graduates in anaesthetic skills, training in Obstrectic Care and Skilled Birth
Attendance, providing for local recruitment of nurses/ANMs, contractual
appointment of doctors, training of Rural Medical Practitioners. Given the
capacity constraints, it is unlikely that these numbers will become available in the
immediate future. Therefore, a systematic, district specific approach will be
required to expand the network of fully equipped facilities. Following suggestions
are made in this regard:
• Ensure that the district hospitals are fully equipped for the FRU services,
• Strengthen midwifery skills of existing ANMs/Nurses through their
attachment to district hospital; add more facilities for skill-development
training after they are fully equipped for FRU services,
• Involvement of non-govt. stake holders in running facilities. Scale up the
training of doctors/ANMs in Skill Birth attendance.
• Training of RMPs.
• Setting up of a nursing cadre in all States.
it*****
33
CHAPTER - 5
METHODS OF IMPROVING REPRODUCTIVE & &CHILD HEALTH
SERVICES AT THE SECONDARY AND TERTIARY LEVELS.
A separate Working Group has been set up by the Planning Commission to look
into the different aspects of service delivery at the Secondary and Tertiary levels.
The group, therefore, did not go into the details of this issue.
34
CHAPTER-6
FINANCIAL
AND
PHYSICAL
REQUIREMENTS
FOR
IMPLEMENTATION OF RCH PROGRAMMES UNDER 11th PLAN.
The RCH-II carries an approved outlay of Rs 40,000 crore over a 5-year period
FY 2005-06 to FY 2009-10. As the NRHM has since been approved for
implementation over a 7-year period starting FY 2005-06 including 11th Plan
period and its outlays subsume the same for RCH-II, the base cost of extension of
RCH-II till the end of 11th Plan period appears to have been covered under
NRHM outlays, as indicated in Table 6.1 (assuming an annual growth of 10% for
sustaining on-going technical interventions).
Table 6.1: Budgetary requirements for RCH-II during 11th Plan (Rs crore)
RCH-II budget
Total
DBS
EAP
Total
Balance for
other NRHM
activities
6500
2507
3693
6200
300
Total NRHM budget
Year
Non
recurring
Recurri
ng
2005-06
2006-07
500
9000
9500
2771
3729
6500
3000
2007-08
1350
11000
12350
2949
4551
7500
4850
2008-09
4290
13000
17290
3137
6363
9500
7790
2009-10
8000
16206
24206
3312
6988
10300
13906
2010-11
10000
23884
33884
3650
7690
11340
22544
2011-12
5000
42439
47439
4015
8460
12475
34964
Total -NRHM duration
151169
63815
87354
Total -11th Plan period
135169
51115
No separate budget approved; figures are estimates assuming 10% nominal enhancement
The Working Group recommends following two suggestions keeping in view the
integration of RCH-II with NRHM :
•
Allow the external grant assistance (with zero debt liability) mobilized by the
Ministry of Health and Family Welfare as an additionality to the domestic
budget, as recommended in the 10th Plan Mid-Term Evaluation Report.
35
•
Develop a year -wise, activity wise detailed expenditure plan for the
NRHM, integrating RCH-II [and other schemes which are subject to inter
national negotiations / agreements] but retaining their separate ‘financial’
identity within the same.
The NRHM Implementation Frame Work approved by the Union Cabinet has
projected the financial and physical needs to fully operationalise the mission to
meet its stated goals based on the projections made by the National Commission
on Macroeconomics and Health in its report. The group felt that this projections
fully cover the requirements of the Maternal and Child Health programmes.
********
36
CHAPTER - 7
RECOMMENDATIONS
Some of the important issues concerning women and children’s health and
welfare which requires special and immediate attention during the 11th Plan
are listed below, on the basis of the recommendations made by the Group.
Gender Based Violence
Large-scale datasets indicate that one in every four women has experienced
spousal violence at least once in her marital union. From an epidemiological
view point the violence results into unwanted pregnancy, pregnancy
complications, miscarriages and other maternal morbidities. Besides impacting
reproductive health, violence also results in variety of medical and
psychological problems, which may assume serious consequences requiring
access to treatment and counseling facilities.
The Eleventh Five-Year Plan should consider public health interventions so as
to prevent gender-based violence in community and also address screening
and management of violence through the network of public health institutions.
•
Pre-natal Sex Selection - Needfor stabilising sex ratios
While family size has become smaller, with more and more families wanting
only two children, the desired family composition in terms of the sex of the
children has not changed. The preference for at least one son is evident. This
further puts daughters at risk, as families want to ensure that one out of the
two children is a son. This finding is further reaffirmed in the recent NFHS 3
study. Low ratios further lower women’s status - violence, movement of
‘brides’, resurgence of negative cultural practices such as polyandry.
Both the mid-term appraisal of the tenth and the eleventh plan approach paper
emphasise the need for stabilising the child sex ratios and for ensuring
effective implementation of the Act accompanied by efforts to influence
behaviour change. The Ministry is actively addressing the issue. To improve
the implementation of the Act it has recently constituted a National
Support and Monitoring Cell. The inspection committee of the Ministry is
undertaking routine visits to district for assessment of records and full
37
compliance of the providers with the provisions of the Act. Computerisation of
the records is underway to facilitate close monitoring and timely action against
defaulters. Other steps for integration of the issue of pre-natal sex selection in
the ministry’s initiatives and programmes include the following:
•
•
•
•
•
•
Community awareness through ASHAs,
integration of the issue in training modules and programme and in
IEC/BCC material,
adding information on sex selection to the medical curriculum,
including indicators on improvement in sex ratios and birth registration as
a part of monitoring target/indicators under RCH 2/NRHM
inclusion of the issue in district level programme planning and
implementation processes,
promoting greater convergence with other departments of ministries such
as DWCD, Panchayati Raj, Youth affairs for a comprehensive service side
and community level response to address the issue
Additional strategies that can be addressed through the Eleventh Plan include:
• Developing targets and monitoring : Develop clear targets of natural sex
ratio at birth (SRB) which is 105 males per 100 females and give
financial benefits to states that have improved SRB. The Annual Health
Survey should also include estimating the SRB at the district level from
2007 on wards. Planning Commission could also consider obtaining
independent estimates of the SRB at the district level each year. The states
should be encouraged to monitor the SRB of the institutional deliveries by
parity for each of the facility and for the districts.
• Resource transfers: Improvement in SRB should be included as one of the
indicators for arriving at decisions on planned assistance to states.
•
Data for tracking: Improve data availability, access and quality, especially
on sex ratio at birth. The option of PHC level enumeration can be
considered to monitor the sex ratio at birth on a routine basis. Adequate
financial resources should be programmed for capacity building,
awareness generation and strict enforcement of PC & PNDT Act. The
PNDT Act should be amended to provide for the independence of the
Appropriate Authorities at the district level from the district health
administration and their accountability to the National Board under the
Act. The amendment should also provide for the National Appropriate
Authority to supervise the functioning of the state and district level
authorities..
38
Promoting institutional deiiveries
(a) As per the demand from the HPS states, enhancement of cash
assistance to mother to be brought at par with that of the EPS states. This
would raise the cash benefit from the existing scale of Rs.700/Rs.600 per
delivery to Rs.UOO/Rs.lOOO/- per delivery in rural and urban areas,
respectively.
(b) Considering that the poor families whether in EPS or HPS states, avoid
going to institutions mainly due to lack of financial support, and that non
availability of BPL certificates impedes access to the benefits of the
scheme in many states, like in the EPS states, all pregnant women in the
HPS states, accessing public or accredited private health institutions
should be brought under the fold of JSY.
(c) Considering that obtaining age certificate is difficult specially in the
rural areas due to low rate of registration of births, like in EPS states, age
restrictions should be removed in HPS states.
(d) Considering that women with high fertility and parity are at grater risk
of mortality and that the JSY is mandated for safe motherhood, restrictions
on number of child, like in EPS states, should be removed for HPS states.
(e) The annual estimated cost of the implementing the JSY would be
around Rs.500.00 crores.
•
Infertility
Nearly 5-8 percent couples report infertility in India. The social
consequences of infertility are disaster to women, as “female sex” is
invariably blamed for not producing children. She may be abandoned and
husband may remarry. Prevention and management of infertility in
primary health care setting should be included in service package delivered
in the NRHM, especially in the states with performing well on programme
delivery indicators.
39
•
Problems of older women
Though reproductive life span ceases at 50 years, many women continue to
suffer with health problems related to reproductive systems. Community
based studies have indicated significant burden of diseases attributable to
chronic reproductive morbidities such as obstetric fistula, pelvic organ
prolapse, and osteoporosis.
•
Reproductive cancers
Data from cancer registry in the country suggest high prevalence of
cervical and breast cancer amongst women. In the XI FYP attempt should
be made to introduce HPV (Human Papilloma Virus Vaccine) in the
programme especially in the states with high prevalence. Similarly centre
of excellence should be developed to screen, diagnose and manage
reproductive cancers in women.
• Mental Health problems of the women
Burden of diseases attributable to mental health problems amongst women
is also high. The range of mental health problems includes anxiety
disorders, depression and psychosis. Considering limited access to
qualified mental health professionals, primary mental health care should be
an integral component of NRHM. Several evidence based interventions
such barefoot counselors (may be ASHAs) could be considered as a first
point of care.
•
Occupational health problems of women
The proportion of women (15-59 yrs) in terms of workforce participation
has gone up in the last census to 40 percent. Most women are in the
unorganized sectors and are not covered for safety provisions. Health
hazards to women working in agriculture include exposure to pesticides,
injuries due to mechanized farm equipments and snakebites etc. Women
are employed in hazardous occupation such as mining, chemical industries
and plantations as well. Similarly women are also exposed to indoor air
pollution especially in rural areas, where clean fuels are still not available
for cooking purposes. Indoor air pollution is also linked with causation of
Acute Respiratory Infections amongst under-five children.
40
Women and Children ’ health in Disaster situations
Pregnant women are susceptible to trauma in disaster situations and high
incidence of spontaneous abortions in the post disaster period is very well
documented. Women are also more vulnerable to violence during these
situations. Similarly, children invariably bear the brunt, as they are unable to run
away from the disaster sites. Since mobility is restricted during disasters,
programmes should focus on addressing health care needs of women and make
provisions for supply of reproductive health commodities including sanitary kits.
Other recommendations:(a)
The Working Group noted that the strategies and interventions proposed under
the NRHM and RCH-II are extremely relevant and hold the biggest potential
for improvement in the health status of women and children. The thrust on
implementing these strategies must receive the highest priority during the 11th
Plan.
(b)
There is a need to enlarge the ambit of NRHM and RCH-II technical
interventions to include issues such as gender based violence, pre-natal sex
selection, infertility, problems of older women, reproductive cancers, mental
health problems, health related ability issues occupational health problems of
women and women and children’s health in disaster situations.
(c)
Both NRHM and RCH-II need to adopt a life cycle approach towards the
health of women and children and in doing so convergent action in association
with related programmes of the health sector as well as of associated
Ministries needs to be taken and reflected in the women and child health
programme of the Ministry. This amongst others will require specific
components to be built in for women and children in the HIV / AIDS,
Communicable (T.B., Malaria, Leprosy etc.) and Non-Communicable
Diseases (Cancer, Diabetes, Circulatory diseases etc.) programmes. Similarly
nutrition including anemia, substance abuse (tobacco, alchohol, drug
dependence), sanitation, drinking water and other issues having a bearing on
the health of children and women would need to be attended by developing
effective linkages so as to ensure a holistic approach towards the health care of
women and children.
(d)
The issues identified in the Approach Paper to 11th Plan like absenteeism of
doctors/health
provides,
low
levels
of
skills,
inadequate
supervision/monitoring and callous attitude are critical issues and must be
41
attended to with all seriousness at both the Central Government and State
Government levels.
(e)
The working group is concerned that there is no accurate methodology for
estimating Maternal Mortality Rates at State and District levels. Steps must be
initiated by the RGI to ensure 100 percent registration of births and deaths
need to be implemented quickly. ASHAs/Health Workers should be fully
utilized. In the registration of births and deaths at the village level.
(f)
Despite all the investments made till now the service delivery network remains
extremely weak both in terms of physical infrastructure as well as human
resources. The development of appropriate crucial technical manpower
resources has to be in the long term matched with the field requirements of
various specialties considered crucial for saving lives of women and children.
The group recommended the up scaling of the trainings initiated by the States
to ensure availability of Skilled manpower to enable operationalisation of First
Referral units in the Community Health Centres to deal with Obstetric
emergencies and childhood illness.
(g)
While efforts to strengthen and optimize existing public facilities with more
investment and better management should receive priority, collaborating with
the private sector, especially the NGO network will still be required due to the
Governments’ limitations in mobilizing the required capital for meeting the
growing demand and more importantly, the expertise and skill base that the
private sector attracts. Collaboration must, however, be funded on a
regulatory framework and insurance system licensed by the Gol to ensure that
there is no adverse selection and risk-sharing is facilitated.
(h)
Organisational set up and structure of State Health Departments / Directorates
differ widely. While there should be no objection to this. Central Government
must insist on clearly defined roles and responsibilities at least where it is
making financial contribution.
(i)
The Block with the block hospital as the apex technical and administrative unit
has been rightly positioned as the basic unit for organizing service delivery.
There is need to have atleast one CHC functional per block in the first phase of
RCH-II. However, in order to make the block health system optimally
functional, there is a need to develop model organogram and job description
for each functionary. This is necessary for functional integration of the various
technical interventions including TB, Malaria and HIV /AIDS.
42
0)
There is an urgent need for developing model protocols for realizing the
communitisation objective defining the processes and procedures involved.
(k)
Health Worker Schemes taken up by some States to cover urban slums under
RCH-II needs to be expanded to all the States. They should be linked to
health posts and hospital to establish a referral chain.
(1)
Considering that a rapid expansion in infrastructure manpower is envisaged
under NRHM, there is a need for involving the district level institutions in
training and skill upgradation. Therefore, a systematic, district specific
approach will be required to expand the network of fully equipped facilities.
Following suggestions are made in this regard:
•
•
•
(m)
Ensure district hospital is fully equipped for the FRU services,
Strengthen midwifery skills of existing ANMs through their attachment to
district hospital; add more facilities for skill-development training after
they are fully equipped for FRU services,
Adopt multiskilling as the main strategy for strengthening service delivery,
both for doctors as well as the paramedical staff.
Nursing / paramedical manpower will have a crucial role in delivery of health
care services and for achieving the MDG goals. The Group strongly feels that
investments in this area will provide more returns in terms of impact and
therefore makes following suggestions:
•
•
•
•
•
•
All states should take action for having a nursing cadre set up in the State.
A dedicated Nursing and Paramedical Manpower Division / Unit should be
established at the National and State levels.
All medical colleges should be mandated to establish a College of Nursing
offering courses in B.Sc. Nursing, M. Sc. Nursing and Post-Basic Diploma
courses in specialty nursing areas.
All District Hospitals should be mandated to establish a school of nursing
offering ANM and Diploma in General Nursing and Midwifery,
Smaller hospitals in public sector having at least 30 OBG beds should be
encouraged to start ANM training
Private sector hospitals having at least 30 OBG beds should also be
allowed to start ANM training programme and the concerned State
Government should allow selected public sector rural facilities for their
field training.
43
•
The cadre of Independent Nurse Practitioner developed by the Indian
Nursing Council needs to be rapidly expanded through sponsorship.
(n)
The internship period in medical colleges is mostly utilized for preparing for
the post graduate courses at the cost of actual field training. This is the major
reason for the doctors posted to rural areas not being in tune with the realities
of health care in field setting. Ways have to be found to arrest this
phenomenon.
(o)
The allocation of seats under PG medical courses needs urgent revision to
provide for more seats in the specialties required in the rural areas.
(P)
The recommendations made by the Task Group on Medical Education setup
by the Ministry need to be examined and finalized quickly to revamp medical
education in the country to match the needs of NRHM.
(q)
Rural Medical practitioners should be trained and utilized in providing
improved quality of service to the rural population.
(r)
A robust MIS needs to be developed by triangulating data and information
from routine reporting systems, external programme evaluations and
community based assessments of programme implementation.
(s)
The National Statistical Commission should approached to guide on the
modalities for undertaking the Annual Health Survey at the district level.
(t)
The PNDT Act should be amended to provide for the independence of the
Appropriate Authorities at the district level from the district health
administration and their accountability to the National Board under the Act.
The amendment should also provide for the national Appropriate Authority to
supervise the functioning of the state and district level authorities.
ASHAs/Health Workers should be fully involved at the village level for
advocacy and tracking of cases.
(u)
The NGO Sector should be revitalized and Strengthened to the support
activities under NRHM. The MNGOs selection for all districts in the country
should be completed and they be fully utilized for a variety of delivery of
services under various national programmes.
44
(V)
The IMNCI (Integrated Management of Neonatal and Childhood Illnessess)
needed to be extended to all the districts phase-wise. Home based New born
care, which is envisaged for ASHAs under NRHM should be taken up on
priority.
(w)
All interventions for Maternal and Child Health need to be closely monitored
component-wise by the ministry.
(X)
Managerial Support as envisaged under the RCH-II/ NRHM should be
extended to the block & PHC level to track funds and monitor the
programmes.
(y)
Organization of monthly health day by integrating ICDS and health activity
should be closely monitored and every level and periodically evaluated to
provide women and children all essential services and monitor and implement
nutritional intervention.
*******
45
Annexure I (a)
No.2(10)/06-HFW
Government of India
Planning Commission
(Health, Family Welfare & Nutrition)
Yojana Bhawan
Sansad Marg
New Delhi
25th May 2006
ORDER
Subject:
Constitution of Working Group on Health of Women &
Children for the Eleventh Five Year Plan (2007-2012)
In the context of formulation of the Eleventh Five Year Plan (2007-12) it has been
decided to set up a Working Group on Health of Women & Children under the Chairmanship
of Secretary, Department of Health & Family Welfare, Government of India. The
composition of the Working Group is as follows:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Secretary(HFW), Ministry of Health and Family Welfare, New Delhi.
Secretary/Representative, Ministry of Women & Child Development, New Delhi.
Director Genera, ICMR, Anasri Nagar, New Delhi._________________
Representative, DGHS, New Delhi._____________________________
Secretary (Health), Government of Tamil Nadu____________________
Secretary (Health), Government of Hamachal Pradesh_______________
Secretary(Health), Government of Kerala________________________
Secretary(Health), Government of Maharashtra____________________
Secretary (Health), Government of Uttar Pradesh___________________
Shri A.Kumar, Director(H&FW), Planning Commission, New Delhi
Shri K.M.Gupta, Director, Ministry of Finance, New Delhi.___________
Representative, WCD Division, Planning Commission, New Delhi.
Dr.S.Menon, Faculty, NIHFW, New Delhi.______________________
Dr.F.Ram, Professor, UPS, Mumbai_____________________________
Dr.Dileep Mavalankar, Professor, IIM, Ahmedabad_________________
Dr.V.a.Pai Panandiker, New Delhi._____________________________
Dr.Saswati Swain, NIAHRD, Cuttack___________________________
Ms.C.P.Sujaya, New Delhi.______________________________ _
Dr.H.Helen, CEPHAD Foundation, Hyderabad____________________
Ms.Sundari Ravindran, Hon.Prof.RCH, Achuta Menon Centre for Health
Sciences, Thiruvananthapuram._______________________________ _
Dr.Enakshi Thakural, Centre for Child Rights, Mumbai______________
Dr.Nerges Mistry, FRCH, Mumbai________ _____________________
Dr.Hanif Lakrawala, Sanchetna, Ahmedabad______________________
Ms.Ena Singh, Assistant Representative, UNFPA, New Delhi_________
Ms.Sudha Tewari, Pariwar Sewa Sansthan, New Delhi.______________
Shri Shikhar Agarwal, Udaipur, Rajasthan________________________
Joint Secretary, Department of Health & Family Welfare, New Delhi.
46
Chairman
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Secretary
2.
The Terms of Reference of the Working Group will be as under:
1) To assess the procedures for estimating mortality / morbidity in women and
children with respect to:
a) Sources of data
b) Accuracy, reliability and geographical distribution
c) Problems in making estimates
d) Suggested remedial measures in ongoing programmes
e) Assessing the achievement in reproductive and child health vis-avis targets set in the National Population Policy 2000 & NRHM.
f) Initiatives during Eleventh Plan to obtain better estimates.
2)
To review ongoing major reproductive and child health programmes
with respect to:
a)
b)
c)
d)
Objectives, strategies, targets and achievements, outlays and
expenditure during 10th Plan period
Problems identified, midcourse corrections made during the 10th
Plan
Proposed strategies, objectives, programmes, targets and outlays
during the Eleventh Plan
Health manpower-current status, projected requirements,
initiatives to achieve required number and type of manpower.
3)
To review the functioning of family welfare infrastructure and
manpower in rural and urban areas and suggest measures for
rationalizing, restructuring the infrastructure, strategies for improving
efficiency of implementation of the programme and for the delivery of
services.
4)
To suggest methods for improving reproductive and child health
activities at secondary and tertiary care levels through:
a)
b)
c)
Improving NGO / private sector / organized sector involvement in
reproductive and child health services;
Increasing financial resources available for reproductive and child
health;
Improving utilization of existing facilities
5)
To project financial / physical requirement for implementation of these
programmes during the Eleventh Plan.
6)
To deliberate and give recommendations on any other matter relevant to
the topic.
3.
The Chairman may form sub-groups and co-opt official or non-official members
as needed. The Working Group will submit its report by 31st August, 2006.
4.
Smt. Radha R.Ashrit, SRO (H&FW), Room No.343, Planning Commission, New
Delhi-110001 will be the nodal officer for all further communications. (Tel.No.230966662383. Email ID: radha-pc@nic.in)
5.
The expenditure on TA/DA in connection with the meetings of the Working
Group in respect of the official members will be borne by the parent Department / Ministry to
47
which the official belongs as per the rules of entitlement applicable to them. The non-official
members of the Working Group will be entitled to TA/DA as per permissible to Grade I
officers of the Government of India under SR 190 (a) and this expenditure will be borne by
the Planning Commission.
Sd/(Ambrish Kumar)
Director (H&FW)
Tel No.23096530
(ambarish.kumar@nic.in)
To Chairman and Members of the Working Group.
Copy to:
1. PS to Deputy Chairman/MOS(Planning)/
Members (KP)/(AS)/(VLC)(BLM)/SH/(BNY)(AH)/Member Secretary, Planning
Commission, New Delhi.
2. All Pr.Advisers/Advisers/HODs in Planning Commission
3. Prime Minister’s Office, South Block, New Delhi.
4. Cabinet Secretariat, Rashtrapati Bhawan, New Delhi.
5. US(Admin.I)/Pay & Accounts Officer/Accounts-I Section, Planning Commission/
DDO, Planning Commission
6. Information Officer, Planning Commission.
(Ambrish Kumar)
Director(H&FW)
48
Annexure I (b)
Composition of the Sub Group
Sl.No.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Name & Designation
Mr.S.S.Brar, JS, MoHFW________________
Dr.Ranjana Kumar, DFID________________
Mrs.Sudha Tewari, Parivar Kalyan Sansthan
Dr. Vinod Paul, Professor of Pediatrics, ARMS
Dr.LP.Kaur, DC (MH)__________________
Dr.N.Namshum, DC (Trg.)_______________
Dr.M.S.Jayalakshmi, DC (RSS)___________
Dr.Manisha Malhotra, AC(MH)___________
Mr.A.P.Singh, Director(DC)______________
Dr.Rattan Chand, Director (PNDT)_________
Mr.K.D.Maiti, Director (MH)_____________
Mr.Sanjeev K.Gupta, Dy.Director(DC) ______
Mrs.Sushma Rath, US (ID & PNDT)_______
Dr.H.Bhushan, AC (MH)
49
Sub Group Status
Chairperson
_____ Member
_____ Member
_____ Member
_____ Member
_____ Member
_____ Member
_____ Member
_____ Member
_____ Member
_____ Member
_____ Member
_____ Member
Convenor
Annexure-II
NRHM : BROAD FRAMEWORK FOR IMPLEMENTATION
A.
Action at the Central level
For development of an effective health system, a broad overview of the current
1.
health status, and development of appropriate policy interventions is necessary.
Regulations and setting standards for measuring performance of public/private sector
in health, issuing guidelines to help the states, development of partnership with non
governmental stakeholders, developing framework for effective interventions through
capacity development and decentralization including transfer of schemes and
financing in the states are areas where the Central Government would continue to play
a role. Effective monitoring of performance, support for capacity development at all
levels, sharing the best national and international practices, and providing
significantly more financial resources to drive reforms and accountability, disease
surveillance, monitoring & evaluation will be the thrust of the Central Government’s
interventions.
B.
Leadership of States
The NRHM is an effort to strengthen the hands of States to carry out the
required reforms. The Mission would also provide additional resources to the States to
enable them to meet the diverse health needs of the citizens. While recognizing the
leadership role of the states in this regard, it is proposed to provide necessary
flexibility to the States to take care of the local needs and socio-cultural variations. In
turn, States will decentralize planning and implementation arrangements to ensure that
need based and community owned District Health Action Plans become the basis for
interventions in the health sector. The States would be urged to take up innovative
schemes to deal with local issues. Keeping in view the decentralization envisaged
under the NRHM, the States would be required to devolve sufficient administrative /
financial powers to the PRIs. At the same time, the States are also required to take
action to increase their expenditure on health sector by at least 10% every year over
the Mission period. The States would also be expected to adhere to mutually agreed
milestones which would be reflected in a MOU to be signed with each State. It may
be mentioned here that even though under RCH-II, an effort has been made to
integrate a number of schemes, there still exists many schemes for which the funds
flow to the States is in a tied manner thus hampering flexibility and presenting
difficulties in monitoring them. Verticality of the programmes has also led to
2.
50
duplication of efforts and thereby wastage of scarce resources. The Central
Government on its part would decentralize most, if not all of the schemes to the states.
The States would also be supported in their endeavor to build capacity for handling
the complex health issues.
C.
Institutionalizing community led action for health
Nearly three fourth of the population of the country live in villages. This rural
3.
population is spread over more than 10 lakh habitations of which 60% have a
population of less than 1000. If the Mission of Health for All is to succeed, the reform
process would have to touch every village and every health facility. Clearly it would
be possible only when the community is sufficiently empowered to take leadership in
health matters. The Panchayati Raj institutions, right from the village to district level,
would have to be given ownership of the public health delivery system in their
respective jurisdiction. Some States like Kerala, West Bengal, Maharashtra and
Gujarat have already taken initiatives in this regard and their experiments have shown
the positive gains of institutionalizing involvement of Panchayati Raj institutions in
the management of the health system. Other vibrant community organizations and
women’s groups will also be associated in communitization of health care.
4.
The NRHM would seek to empower the PRIs at each level i.e. Gram
Panchayat, Panchayat Samiti (Block) and Zilla Parishad (District) to take leadership
to control and manage the public health infrastructure at district and sub district
levels.
• The Village Health and Sanitation Committee (VHSC) will be formed in each
village (if not already there) within the over all framework of Gram Sabha in
which proportionate representation from all the hamlets would be ensured.
Adequate representation to the disadvantaged categories like women, SC / ST /
OBC / Minority communities would also be given.
• The Sub Health Centre will be accountable to the Gram Panchayat and shall
have a local Committee for its management, with adequate representation of
VHSCs.
• The Primary Health Centre (not at the block level) will be responsible to the
elected representative of the Gram Panchayat where it is located. All other
Gram Panchayats covered by the PHCs would be suitably represented in its
management.
• The block level PHC and CHC 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.
51
•
•
The Zilla Parishad at the district level will be directly responsible for the
budgets of the health sector and for planning for people’s health needs.
With the development and capacities and systems the entire public health
management at the district level would devolve to the district health society
which would be under the effective leadership and control of the district
panchayat, with participation of the block panchayats.
5.
To institutionalize community led action for health, NRHM has sought
amendments to acts and statutes in States to fully empower local bodies in effective
management of the health system. NRHM would attempt to transfer funds,
functionaries and functions to PRIs. Concerted efforts with the involvement of NGOs
and other resource institutions are being made to build capacities of elected
representatives and user group members for improved and effective management of
the health system. To facilitate local action, the NRHM will provide untied grants at
all levels [Village, Gram Panchayat, Block, District, VHSC, SHC, PHC & CHC].
Monitoring committees would be formed at various levels, with participation of PRI
representatives, user groups and CBO / NGO representatives to facilitate their inputs
in the monitoring planning process, and to enable the community to be involved in
broad based review and suggestions for planning. A system of periodic ‘Jan Sunwai’
or ‘Jan Samvad’ at various levels would empower community members to engage in
giving direct feedback and suggestions for improvement in Public health services.
D.
Promoting Equity
6.
This is one of the main challenges under NRHM. Empowering those who are
vulnerable through education & health education, giving priority to
areas/hamlets/households inhabited by them, running fully functional facilities,
exemption for below poverty line families from all charges, ensuring access, risk
pooling, human resource development / capacity building, recruiting volunteers from
amongst them are important strategies under the Mission. These are reflected in the
planning process at every level. Studies have revealed the unsatisfactory health
indicators of socially and economically deprived groups and NRHM makes conscious
efforts to address this inequity. The percentage of vulnerable sections of society using
the public health facilities is a benchmark for the performance of these institutions.
E.
Promoting Preventive Health
As stated earlier, the Health System in the country is oriented towards curative
7.
Health. The NRHM would increase the range and depth of programmes on Health
Education / IEC activities which are an integral part of activities under the Mission at
52
every level. In addition it would work with the departments of education to make
health promotion and preventive health an integral part of general education. The
Mission would also interact with the Ministry of Labour for occupations health and
the Ministry of women and child for women and child health to ensure due emphasis
on preventive and promotive health concerns.
F.
Dealing with Chronic Diseases
India has one of the highest disease burdens in the world. The number of
8.
deaths due to chronic diseases are expected to rise from 3.78 million in 1990 (40-47%
of all deaths) to 7.63 million by 2020 (66.7% of all deaths). Tobacco, cancer, diabetes
and renal diseases, cardio vascular diseases, neurological diseases and mental health
problems and the disability that may arise due to the chronic diseases are major
challenges the Mission has to deal with. The already over stretched health system has
to absorb the additional burden of chronic diseases, especially in the rural areas. Both
preventive and curative strategies along with mobilization of additional resources are
needed. It is proposed to integrate these with the regular health care programmes at
all levels.
G.
Reducing child and maternal mortality rates and reducing fertility rates population stabilization through quality services
NRHM provides a thrust for reduction of child and maternal mortality and
reduce the fertility rates. The approach to population stabilization is to provide quality
heath services in remote rural areas along with a wide range of contraceptive choices
to meet the unmet demand for these services. Efforts are on be to provide quality
Reproductive Health Services (including delivery, safe abortions, treatment of
Reproductive tract infections and Family Planning Services to meet unmet needs,
while ensuring full reproductive choices to women). The strategy also is to promote
male participation in Family Planning.
Reduction of IMR requires greater
convergent action to influence the wider determinants of health care like female
literacy, safe drinking water, sanitation, gender and social empowerment, early child
hood development, nutrition, marriage after 18, spacing of children, and behavioral
changes etc. Within the health sector, the thrust is on promoting Integrated
Management of Neo natal and child care (IMNCI). The main strategy for maternal
mortality focuses on safe/institutional deliveries at functional health facilities in the
governmental and non-governmental sectors. Efforts to develop competencies needed
for Skilled Birth Attendants (SBAs) in the entire cadre of Staff Nurses and ANMs as
also in select medical officers will also be undertaken. Regular training of select
Medical Officers to administer anesthesia has been taken up. Also multi skill training
9.
53
of Medical Officers, ANMs and Para-medics will be initiate to close specialist skill
gaps. Intensified IEC would be pursued to ensure behavioral changes that relate to
better child survival and women’s health i.e. breast feeding, adequate complementary
feeding of the young child, spacing, age at marriage, education of the girl child.
Adolescent health is another area of action under the NRHM. CHCs are being
upgraded to FRUs for providing referral services to the mother and child and taking
care of obstetric emergencies and complications for provision of safe abortion
services and for prevention, testing/counseling in respect of HIV AIDS. Reduction in
IMR/MMR will also be closely monitored through social audit, which is being
introduced at the Panchayat level.
H.
Management of NRHM activities at State / District / Sub district level
Block Level Pooling
The success of decentralization experiment would depend on the strength of
the pillars supporting the process. It is imperative that management capacities be built
at each level. To attain the outcomes, the NRHM would provide management costs
upto 6% of the total annual plan approved for a State/district as has been introduced
under the RCH-II programme. Apart from medical and para-medical staff, such
services would include skills for financial management, improved community
processes, procurement and logistics, improved collection and maintenance of data,
the use of information technologies, management information system and improved
monitoring and evaluation etc. The NRHM would also establish strong managerial
capacity at the block level as blocks would be the link between the villages and the
districts. At the district level the Mission would support and insist on developing
health management capacities and introducing policies in a systematic manner so that
over time all district programme officers and their leadership are professionally
qualified public health managers. Management structures at all levels will be
accountable to the Panchayati Raj institutions, the State Level Health Mission and the
National Level Missions/Steering Group.
10.
I
11.
The amount available under the management cost could also be used for
improving the work environment as such improvements directly lead to better
outcomes.
The management structure holds the key to the success of any
programme and efforts to develop appropriate arrangements for effectively delivery of
NRHM with detailing, will be a priority. Clarity of tasks, fund flows, powers,
functions, account keeping, audit, etc. will be attempted at all levels.
54
12.
Based on the outcomes expected in NRHM, the existing staff of Health
Departments at SHC, PHC, CHC, Block, District, State and National levels are being
carefully assessed to see how structures can be reoriented to deliver more efficiently
and effectively. States will constantly undertake review of management structure and
devolution of powers and functions to carry out any mid course correction. Block
Level Pooling will be one of the priority activity under the NRHM. Keeping in view
the time line needed to make all facilities fully functional, Specialists working in
PHCs would be relocated at CHCs to facilitate their early conversion to FRUs.
Outreach programmes are being organized with “block pooled” CHCs as the nodal
point. NRHM will attempt to set up Block level managerial capacities as per need.
Creation of a Block Chief Medical Officer’s office to support the supervision of
NRHM activities in the Block, would be a priority. Support to block level CHCs will
also aim at improving the mobility and connectivity of health functionaries with
support for Ambulances, telephones, computers, electric connection, etc.
I.
Human resources for rural areas
Improvement in the health outcomes in the rural areas is directly related to the
13.
availability of the trained human resources there. The Mission aims to increase the
availability through provision of more than 4 lakh trained women as ASHAs /
Community Health Workers (resident of the same village/hamlet for which they are
appointed as ASHA). The Mission also seeks to provide minimum two Auxiliary
Nurse Mid-wives (ANMs) (against one at present) at each Sub Health Centre (SHC)
to be fully supported by the Government of India. Similarly against the availability of
one staff nurse at the PHC, it is proposed to provide three Staff Nurses to ensure
round the clock services in every PHC. The Out-patient services would be
strengthened through posting/ appoint on contract of AYUSH doctors over and above
the Medical Officers posted there. It will be for the States to decide whether they
would integrate AYUSH by collocation at PHC or by new contractual appointment.
GO I support will be for all new contractual posts and not for existing vacancies that
States have to fill up. The Mission seeks to bring the CHCs on a par with the Indian
Public Health Standards (IPHS) to provide round the clock hospital-like services. As
far as manpower is concerned, it would be achieved through provision of seven
Specialists as against four at present and nine staff nurses in every CHC (against
seven at present). A separate AYUSH set up would be provided in each CHC/PHC.
Contractual appointment of AYUSH doctors will be provided for this purpose. This
would be reflected in the State Plans as per their needs.
24.
Given the current problems of availability of both medical as well as
paramedical staff in the rural areas, the NRHM seeks to try a range of innovations and
55
experiments to improve the position. These include incentives for compulsory rural
posting of Doctors, a fair, transparent transfer policy, involvement of Medical
Colleges, improved career progression for Medical / Para Medical staff, skill
upgradation and multi-skilling of the existing Medical Officers, ANMs and other Para
Medical staff, strengthening of nursing / ANM training schools and colleges to
produce more paramedical staff, and partnership with non governmental stakeholders
to widen the pool of institutions. The Ministry has already initiated the process for the
upgradation of ANMs into Skilled Birth Attendants (SBA) and for providing six
month anaesthesia course to the Medical Officers. Convergence of various schemes
under NRHM including the disease control programmes, the RCH-II, NACO, disease
surveillance programme, would also provide for optimum / efficient utilization of all
paramedical staff and help to bring down the operational costs.
J.
National and State level Resource Centres for capacity development
15.
Decentralized Planning, preparation of District Plans, community ownership
of the health delivery system and inter-sectoral convergence are the pillars on which
the super-structure of the NRHM would be built. The implementation teams
particularly at district and state levels would require development of specific skills.
Even at the Central level, the program management unit within the MOHFW would
need technical and management support from established professionals in the field.
The institutions like National and State Institutes for Health and Family Welfare
which were primarily conceived as research and training organizations may not fit the
bill for this purpose. The National Health System Resource Centre (NHSRC), which
is envisaged as an agency to pool the technical assistance from all the Development
Partners, would be ideal for this purpose. Mandated as a single window for
consultancy support, the NHSRC would quickly respond to the requests of the Centre/
States /Districts for providing technical assistance for capacity building not only for
NRHM but for improving service delivery in the health sector in general. It is
proposed to have one NHSRC at the national level and another Regional Centre for
the North Eastern region. State level Resource Centres will be provided for EAG
States on a priority to enable innovations and new technical skills to develop in the
health system. In addition to the above a number of already existing reputed bodies
with national caliber may be strengthened and facilitated to mentor state health
resource centres and district resource groups so that they are able to support the state
level planning efforts.
16.
The NRHM would also require a comprehensive plan for training at all levels.
While efforts are being made to strengthen the NIHFW, the States have been asked to
closely examine the training infrastructure available within the state including State
56
Health & Family Welfare Institute, ANM Training Centres, Medical Colleges,
Nursing Colleges etc. and identify the investment required in them to successfully
carry out the training/sensitization programmes. Comprehensive training policy is
being developed to provide support for capacity building at all levels including
PRIs/Community. NRHM will particularly encourage involvement of Medical
Colleges and Hospitals to strengthen systems of capacity building in the rural health
care set up.
K.
Drug supplies and logistics management
Timely supply of drugs of good quality which involves procurement as well as
17.
logistics management is of critical importance in any health system. The current
system in most states leaves much to be desired. However, there are a few notable
exceptions like Tamil Nadu which has developed a very effective system of supplies
and logistics. Under most of the Centrally Sponsored Programmes, it is the Central
Government which does the procurement of equipments and medicines on behalf of
the States. Most States are reluctant to take responsibility for procurement primarily
because they lack the capacity to take up large scale procurement of goods and
services.
18.
At the level of the Central Government, with the support of the World Bank
and the DFID, an Empowered Procurement Wing (EPW) has been set up which
would be the nodal agency for all procurement matters. While as an interim measure,
till such time that the capacities are built in the States, the EPW would get rate
contracts for drugs, quality testing etc. with the assistance of public sector agencies
like HLL, HSCC prepared and share them with the States for their use. In the long
run, NRHM would like the procurement to take place in a decentralized manner at the
district level. It would take up the capacity building exercise for this purpose in right
earnest. It supports State led initiatives for capacity building and setting up State
Procurement Systems and Distribution Networks for improved supplies and
distribution. In order to take informed procurement decisions, market intelligence is of
utmost importance. The EPW is getting a market survey done to collect information
about the drugs and vaccines which are procured under the RCH-II. This database,
which this market survey would generate, would be updated through annual market
surveys. These would be shared with the states to help them in taking informed
procurement decisions.
57
L.
Monitoring / Accountability Framework
19.
The NRHM proposes an intensive accountability framework through a three
pronged process of community based monitoring, external surveys and stringent
internal monitoring. Facility and Household Survey, NFHS-II, RHS (2002) would act
as the baseline for the mission against which the progress would be measured.
20.
While the process of communitization of the health institutions itself would
bring in accountability, the NRHM would help this process by wide dissemination of
the results of the surveys in a language and manner which could be understood by the
general population. It would be made compulsory for all the health institutions to
prominently display information regarding grants received, medicines and vaccines in
stock, services provided to the patients, user charges to be paid (if any) etc, as
envisaged in the Right to Information Act. The community as well as the Patient
Welfare Committee would be expected to monitor the performance of the health
facilities on those parameters. Health Monitoring and Planning Committees would be
formed at PHC, Block, District and State levels to ensure regular community based
monitoring of activities at respective levels, along with facilitating relevant inputs for
planning. Organisation of periodic Public hearings or dialogues would strengthen the
direct accountability of the Health system to the community and beneficiaries. The
Mission Steering Group and the Empowered Programme Committee at the Central
and the State level will also monitor progress periodically. The NRHM is committed
to publication of Public Reports on Health at the State and the district levels to report
to the community at large on progress made. The Planning Commission will also
carry out periodic monitoring and concurrent evaluation of NRHM. The Mission will
also appoint Special Rapporteurs to carry out field visits and supervision of
programmes. The NRHM would involve NGOs, resource institutions and local
communities in developing this monitoring arrangement. The Mentoring Group on
ASHA, the National Advisory Committee on Community Action (which have been
constituted with the leading NGOs as their members) and the Regional Resource
Centres would provide valuable inputs to the Mission. A wide network of MNGOs,
FNGOs / SNGOs would also be providing feedback to the Mission.
21.
The periodic external, household and facility surveys would track the
effectiveness of the various activities under the NRHM for providing quality health
services. Beside these surveys. Supervision Missions would be conducted twice in
every state to help monitor the outcomes. A computer based MIS would be developed
using the network being set up by the IDSP for rigorous monitoring of the activities.
58
1
22.
The requirements of audit will apply to all NRHM activities. The National,
State and District Health Missions will be subject to annual audit by the CAG as well
as by a Chartered Accountant and any special audit that the Mission Steering Group
may deem fit. Special audit by agencies like the Indian Public Auditors of India could
also be undertaken. Every State will also be supervised by one or more research and
resource institutions who may be contracted for this purpose. All procedures of
government regarding financial grants including Utilization Certificates etc. would
apply to the State and District Health Societies.
23.
For the accountability framework to be truly community owned, the effort will
be to ensure that at least 70 percent of the total NRHM expenditures are made by
institutions and organizations that are being supervised by an institutional
PRI/community group.
Monitoring outcomes of the Mission
• Right to health is recognized as inalienable right of all citizens as brought out
by the relevant rulings of the Supreme Court as well as the International
Conventions to which India is a signatory. As rights convey entitlement to the
citizens, these rights are to be incorporated in the monitoring framework of the
Mission. Therefore, providing basic Health services to all the citizens as
guaranteed entitlements will be attempted under the NRHHM.
• Preparation of Household specific Health Cards that record information on the
following - record of births and deaths, record of illnesses and disease, record
any expenditure on health care, food availability and water source, means of
livelihood, age profile of family, record of age at marriage, sex ratio of
children, available health facility and providers, food habits, alcohol and
tobacco consumption, gender relations within family, etc, (by
ASHA/AWW/Village Health Team).
• Preparation of Habitation/Village Health Register on the basis of the
household Health Cards. ( By the Village Health Team)
• Periodic Health Facility Survey at SHC, PHC, CHC, District level to see if
service guarantees are being honoured.[By district /Block level Mission
Teams/ research and resource institutions].
• Formation of Health Monitoring and Planning Committees at PHC, Block,
District and State levels to ensure regular monitoring of activities at respective
levels, along with facilitating relevant inputs for planning.
• Sharing of all data and discussion at habitation/ village level to ensure full
transparency.
• Display of agreed service guarantees at health facilities, details of human and
financial resources available to the facility.
59
•
•
M.
Sample household and facility surveys by external research
organizations/NGOs.
Public reporting of household and health facility findings and its wider
dissemination through public hearings and formal reporting.
Convergence within the health department
24.
The Ministry of Health & Family Welfare [MOHFW] has a large number of
schemes to support states in a range of health sector interventions. Many of these
programmes pertain-to disease specific control programmes. Many others relate to
programmes for Family Welfare. Special programmes have been initiated as per need
for diseases like TB, Malaria, Filaria, HIV AIDS etc. While the disease specific focus
has helped in providing concerted attention to the issue, the weak or absent integration
with other health programmes has often led to lack of coordination and convergent
action. All central programmes have worked on the assumption that there is a credible
and functional public health system at all levels in all parts of the country. In practice,
in many parts of the country, the public health system has not been in a satisfactory
state. The challenge of NRHM, therefore, is to strengthen the public health institutions
like SHC/PHC/CHC/Sub Divisional and District Hospitals. This will have positive
consequences for all health programmes. Whether it is HIV/AIDS, TB, Malaria or any
other disease, NRHM attempts to bring all of them within the umbrella of a
Village/District/State Health Plan so that preventive, promotive and curative aspects
are well integrated at all levels. The intention of convergence within the Health
Department is also to reorganize human resources in a more effective and efficient
way under the umbrella of the common District Health Society. Such an integration
within the Health Department would make available more human resources with the
same financial allocations. It would also promote more effective interventions for
health care. To help the States achieve inter sectoral convergence, appropriate
guidelines would be issued to the districts.
25.
The pandemic of HIV/AIDS requires convergent action within the health
system. By involving health facilities in the programme at all stages, it is likely to
help early detection, effective surveillance and timely intervention wherever required.
The NACO has presence only from district level upwards. The NRHM would enable
the NACO to provide necessary investment and support to the programme at district
and sub district levels. While NACO will provide Counsellors at CHCs and PHCs as
also testing kits as a part of the NACP - III, it would also help to integrate training on
HIV/AIDS to Medical Officers, ANMs, para medicals and lab technicians. Common
programmes for condom promotion and IEC are also planned. NRHM seeks to
60
improve outreach of health services for common people through convergent action
involving all health sector interventions.
N.
Convergence with other departments
26.
The indicators of health depend as much on drinking water, female literacy,
nutrition, early childhood development, sanitation, women’s empowerment etc. as
they do on hospitals and functional health systems. Realizing the importance of wider
determinants of health, NRHM seeks to adopt a convergent approach for intervention
under the umbrella of the district plan. The Anganwadi Centre under the ICDS at the
village level will be the principal hub for health action. Likewise, wherever village
committees have been effectively constituted for drinking water, sanitation, ICDS etc.
NRHM will attempt to move towards one common Village Health Committee
covering all these activities. Panchayti Raj institutions will be fully involved in this
convergent approach so that the gains of integrated action can be reflected in District
Plans. While substantial spending in each of these sectors will be by the concerned
Department, the Village Health Plan/District Plan will provide an opportunity for
some catalytic resources for convergent action. NRHM household surveys through
ASHA, AWW will target availability of drinking water, firewood, livelihood,
sanitation and other issues in order to allow a framework for effective convergent
action in the Village Health Plans. The Ministry has constituted an inter Departmental
Committee on convergence with the Mission Director as Chairman. This Committee
reports to the EPC. Convergence is also envisaged at the level of the MSG which has
representation of all the concerned Ministries. Similar mechanisms are available at the
State level. Convergence with the Department of Women and Child Development and
with AYUSH has been clearly outlined and shared with States. Necessary guidelines
on inter sectoral convergence are being issued by the Ministry.
27.
The success of convergent action would depend on the quality of the district
planning process. The District Health Action Plans will reflect integrated action in all
section that determine good health - drinking water, sanitation, women’s
empowerment, adolescent health, education, female literacy, early child development,
nutrition, gender and social equality. At the time of appraisal of District Health Plan,
care would be taken to ensure that the entire range of wider determinants of health
have been taken care of in the approach to convergent action.
61
O.
Role of Non Governmental Organizations
The Non-governmental Organizations are critical for the success of NRHM.
28.
The Mission has already established partnerships with NGOs for establishing the
rights of households to health care. With the mother NGO programme scheme, 215
MNGOs covering nearly 300 districts have already been appointed. Their services are
being utilized under the RCH-II programme. The Disease Control programmes, the
RCH-I1, the immunization and pulse polio programme, the JSY make use of
partnerships of variety of NGOs. Efforts are being made to involve NGOs at all levels
of the health delivery system. Besides advocacy, NGOs would be involved in
building capacity at all levels, monitoring and evaluation of the health sector, delivery
of health services, developing innovative approaches to health care delivery for
marginalized sections or in underserved areas and aspects, working together with
community organizations and Panchayti Raj institutions, and contributing to
monitoring the right to health care and service guarantees from the public health
institutions. The effort will be to support/ facilitate action by NGO networks of NGOs
in the country which would contribute to the sustainability of innovations and
people’s participation in the NRHM.
29.
A Mentoring Group has already been set up at the national level for ASHAs to
facilitate the role of NGOs. Grants-in-aid systems for NGOs will be established at the
District, State and National levels to ensure their full participation in the Mission.
P.
Risk pooling and the poor
30.
Household expenditure on Health Care in India was more than Rs. 100, 000
crore in 2004-05. Most of it was out of pocket and was incurred during health distress
in unregulated private facilities, leading to the vicious circle of indebtedness and
poverty. As a matter of fact, in a country of over a billion people, barely 10 million
are covered under the private health insurance schemes. Even if we take into account
Social Health Insurance Schemes like CGHS, ESIS etc., the coverage increases only
to 110 million of which only 30 million are poor. In order to reduce the distress of
poor households, there is therefore an imperative need for setting up effective risk
pool systems. Involvement of NGOs and community based organizations as insurance
providers and as third party administrators can help to generate more confidence in
the risk pooling arrangement being pro-people and in the interests of poor households.
Innovative and flexible insurance products need to be developed and marketed that
provide risk pooling from government and non governmental facilities.
62
31.
While setting up of effective health insurance system is clearly a very
important mission goal, it is realized that the introduction of such a system without the
back up of a strong preventive health system and curative public health infrastructure
would not be cost effective. Such a venture would only end up subsidizing private
hospitals and lead to escalation of demand for high cost curative health care. The first
priority of the Mission is therefore to put the enabling public health infrastructure in
place.
32.
While the private insurance companies would be encouraged to bring in
innovative insurance products, the Mission would strive to set up a risk pooling
system where the Centre, States and the local community would be partners. This
could be done by resource sharing, facility mapping, setting standards, establishing
standard treatment protocols and costs, and accreditation of facilities in the non
governmental sector.
33.
Primary health care would be provided without any charge. However, in the
case of need for hospitalization, CHCs would be the first referral unit. Only when the
CHC is not in a position to provide specialized treatment, a patient would be referred
to an accredited private facility/teaching hospital. The patient would have the choice
of selecting any provider out of the list of hospitals accredited by the District Health
Mission. Reimbursement for the services would be made to the hospitals based on the
standard costs for various interventions decided by the experts from time to time.
34.
It is envisaged that the hospital care system would progressively move
towards a fully funded universal social health insurance scheme. Under such a system,
the government facilities would also be expected to earn their entire requirement of
recurring expenditure including the salary support out of the procedures they perform,
while taking care that access to those who cannot pay is not compromised. This
system would obviously work only when the personnel working in the CHCs are not
part of a state cadre but are recruited locally at the district level by the District Health
Mission on contract basis. Since evolving such a system is likely to take some time, at
the first instance, it is proposed to give control of the budget of the CHC/ Sub
Divisional and District Hospitals to the Rogi Kalyan Samitis or equivalent public
bodies set up for efficient management of these health institutions. Efforts to develop
risk pooling arrangements as partnerships of the Central, State and local Governments
along with community organizations, will be attempted. A possibility of two thirds of
the resource support coming from government and one third to be collected from
those who can afford to run a public health system based risk pool arrangement would
also be experimented with, in partnership with states.
63
Q.
Reforms in Medical/Nursing Education
35.
The need for trained human resources, medical as well as para medical for
rural areas has already been brought out. The medical / para medical education system
would require a new orientation to achieve these objectives. While the existing
colleges would require strengthening for increased seat capacity, a conscious policy
decision would be required to promote new colleges in deficient states. A fresh look
also needs to be given on the norms for setting up new medical colleges under the
regulations framed under Indian Medical Council Act to see whether any relaxation is
necessary for such areas. The viability of using the caseload at district hospital for
setting up Govt / private medical colleges would also be examined. Apart from
creating teaching infrastructure at the district level, it would also promote much
needed investment and improvement in tertiary care in the district hospitals.
36.
The curriculum in the Medical Colleges perhaps give undue emphasis on
specialization and tertiary care which is available only in large cities. In the syllabus,
the primary health care as well as preventive aspects of health are largely ignored. It
is therefore natural for the students to aspire for a career in a big hospital in urban
setting. In the process the health care in the rural areas suffers. The Mission would
look at ways and means to correct the situation.
37.
The NRHM also recognizes the need for equipping medical colleges and other
suitable tertiary care centres - including select district hospitals, select not for profit
hospitals and public sector undertaking run hospitals for a variety of special courses to
train medical officers in short term courses to handle a large number of essential
specialist functions in those states where medical colleges and postgraduate courses
are below recommended norms. This includes courses from multi skilling serving
Medical Officers, specially for anesthesia, emergency obstetrics, emergency pediatrics
especially new bom care, safe MTP services, mental health, eye care, trauma care etc.
Further short term progammes are needed to upgrade skills of nurses and ANMs to
that of nurse-practitioners for those centres/regions which potentially have adequate
nurses, but a chronic shortage of doctors over at least two decades.
38.
The Mission would support strengthening of Nursing Colleges wherever
required, as the demand for ANMs and Staff Nurses and their development is likely to
increase significantly. This would be done on the basis of need assessment,
identification of possible partners for building capacities in the governmental and non
governmental sectors in each of the States/UTs, and ways of financing such support
64
in a sustainable way. Special attention would be given to setting up ANM training
centres in tribal blocks which are currently para-medically underserved by linking up
with higher secondary schools and existing nursing institutions.
Efforts to improve skills of Registered Medical Practitioners would also be
39.
introduced. The NRHM recognizes the need for universal continuing medical
education programmes which are flexible and non threatening to the medical
community, but which ensures that they keep abreast of medical advances, and have
access to unbiased medical knowledge, and adequate opportunity to refresh and
continuously upgrade existing knowledge and skills.
R.
Pro-people partnerships with the non-governmental sector
The Non-governmental sector accounts for nearly 4/5 of health expenditure in
40.
India. In the absence of an effective Public Health System, many households have to
seek health care during distress from the Non-governmental sector. A variety of
partnerships are being pursued under the existing programmes of the Ministry,
especially the RCH-II and independently by the States with their own resources with
non governmental partners. Under NRHM, Task Forces are set up with experts,
institutional representatives and NGOs. The RCH-II has development partners,
including UN agencies. Under this the States are trying contract in, contract out, out
sourcing, management of hospital facilities by leading NGOs, hiring staff, service
delivery, including family planning services, MTP, treatment of STI/RTI, etc.
Franchising and social marketing of contraceptives are already built into the FW
programmes. The Immunization and Polio Eradication Programmes effectively make
use of partnerships with WHO, UNICEF, the Rotary Intemationl, NGOs etc. The
Janani Suraksha Yojana (JSY) has also factored in accreditation of private facility for
promotion of institutional delivery. The Disease Control programmes make use of
NGO partnerships in a big way. The Ministry also has strong relations with FOGSI,
IMA, IPHS etc. which are professional Associations for dissemination of information,
advocacy, creating awareness, HRD etc.
41.
The Non-governmental sector being unregulated, the rural households have to
face financial distress in meeting the costs of health care. The NRHM attempts to
provide people friendly regulation framework that promotes ethical practice in the
non-governmental sector. It also encourages non-governmental health providers to
provide quality services in rural areas to meet the shortage of health facilities there.
Such efforts will involve systems of accreditation and treatment protocols so that
ethical practice becomes the basis for health interventions. NRHM encourages
training and up-gradation of skills for non-governmental providers wherever such
65
efforts are likely to improve quality of services for the poor. Arrangements for
demand side financing to meet health care needs of poor people in areas where the
Public Health System is not effective will also be attempted under the NRHM. The
NRHM recognizes that within the non-governmental service there is a large
commercial private sector and a much smaller but significant not for profit sector.
The not-for-profit centres which are identified as setting an example of pro-poor,
dedicated community service would be encouraged used as role model, benchmark,
site of community centered research and training to strengthen the public health
system and improve the regulatory frameworks for the non governmental sector as a
whole.
* * 9|C ](C * *
66
Annexure-III
CONCURRENT ASSESSMENT AND TECHNICAL SUPPORT TO
DISTRICTS IN UTTAR PRADESH
Goal and objectives
The main goal of ongoing Concurrent Assessment and Technical Assistance to
districts (CATA), under the European Commission supported Sector Investment
Programme (SIP) in the state of Uttar Pradesh, is to asses continuously the system of
health care delivery in relation to National Family Welfare Programme and suggest
interventions for improving the service delivery, bring about a quantitative
improvement by removing weaknesses of the system and build the capacity of state
and district level health managers in order to meet the challenges by involving
medical and health teaching institutions of the state of Uttar Pradesh.
The activity has following major objectives,
a) To develop a health intelligence information system at the state and districts'
level for National Family welfare Programme and other health programmes.
b) To use this system for ongoing assessment and mid course correction in the
programmes at different level.
c) Formulation and development of long-term planning and policy, based on
information collected under the system.
d) To make the system available for research and development in the area of
public health management.
e) To get profile of state, districts and large cities, separately.
f) Technical Assistance to district health & family welfare authorities, which has
been reconstituted as District Health Society and District Health Mission
under the NRHM .
g) Capacity building of Medical Colleges and District Health & Family Welfare
Authority/ District Health Mission/ District Health Society.
Implementation arrangement
The Programme is being implemented by a network of institutions working in the area
of public health, community medicine and programme evaluation. The Directorate
General of Family Welfare, Government of Uttar Pradesh has executed a
Memorandum of Understanding (MoUs) with King George Medical University
Lucknow and a number of participating institutions for organizing and carrying out
the study and providing technical support outlined as under.
67
Coordinating Agency: The CATA is being coordinated by the Upgraded Department
of Community Medicine, KG Medical University, Lucknow. Among others, this
involves overall coordination and supervision of the programme, strategy formulation,
liaison with DG Family Welfare Govt, of UP and all participating institutions,
selection of sample of clusters for participating institutions, qualitative monitoring of
the work undertaken by the participating institutions, collation of district / city level
data / results through partners, preparation of integrated reports for submission to the
Government and other agencies, release of funds to the participating institutions,
auditing and submission of expenditure reports.
Participating Institutions: The initial list of participating institutions includes all
Medical Colleges in the State, Central Universities' Medical College/ institute in the
state, Population Research Centre, University of Lucknow and Sanjay Gandhi
Postgraduate Institute of Medical Sciences, Lucknow.
Core Technical Team: The Technical, administrative and financial protocols have
been developed by a core team headed by an officer from the Directorate General of
Family Welfare with the representatives of Coordinating agency (KGMU, Lucknow)
and selected participating institutions and SIFPSA. The core technical teal is
responsible for following functions
(a) finalizing the survey instruments methodology, including the lay
out and format for the reports to be generated by the participating
institutions
(b) determine the qualification and selection process for surveyors and
supervisors as well as to make arrangements for their training.
(c) qualitative monitoring, and
(d) collating the data received from the participating institutions to
generate consolidated reports and its comparative analysis vis-a-vis
results of the surveys commissioned by GOI and other agencies.
Concurrent Assessment process: Every participating institution is assigned a
number of districts. The first choice for surveyors was the students from the
participating institutions and/or other teaching institutions and the district and sub
district level staff. However, later on, professional surveyors had to be engaged and
trained because the students could not remain available round the year due to their
academic schedule and most of the districts have significant shortage of staff. Every
participating institution also employs at least one supervisor for each district for local
68
coordination and ensuring qualitative monitoring. The institution also attempts to
develop a network of local supervisors in the districts for hands-on training.
The members of Core Technical Team visit at least 10% of clusters during the survey,
for qualitative monitoring. The assessment survey is conducted as per the standard 30cluster methodology (WHO recommended). However, the core committee
recommended some adaptations and modifications with a view to build a database,
meeting qualitative monitoring of the RCH programme.
Every participating institution prepares a district wise report and submits to the
coordinating institution for validation. After the report has been finalized, the
participating institution presents the report in a meeting of departmental officers at the
district headquarters, so that they get a first-hand account of their districts. The
presentation also dwell into probable interventions to improve the situation.
Study Design and Methodology
Study area: The survey covers the urban and rural areas of all the seventy districts of
Uttar Pradesh. The districts are divided into two categories (a) districts with major
cities/urban areas (total no. 12), and (b) districts with minor cities/urban areas (total
no. 58). In category (a) districts, rural and urban areas are considered as separate units
for the survey and report generation, whereas in category (b) districts rural and urban
areas combined together will form an unit of study and report generation.
Sampling Technique: The sampling technique of this study is based on the WHO
thirty cluster methodology. The thirty clusters are selected from the districts of
category (a) described above, separately for rural and urban areas. From districts of
category (b), thirty clusters are selected from rural and urban areas combined together.
Sampling unit (cluster) for rural area is a revenue village and for urban area, it is a
municipal ward. The selection is based on systematic sampling scheme with
population proportional to size.
Sampling Procedure: For selecting rural clusters in a district, all revenue villages are
listed with their total population according to census 2001. The villages are arranged
in the same order as they appear in the census list. A random number, less or equal to
sampling interval, is selected. The village, corresponding to cumulative population
equalled or exceeded the random number, is selected as the first cluster. The sampling
interval is added to the random number and a new number is obtained. Subsequent
village corresponding to cumulative population equalled or exceeded to new number
is selected as second cluster. Similarly the third, fourth and subsequent clusters are
selected by adding the sampling interval to the obtained numbers. For selection of
clusters in urban areas of category (a) districts, municipal wards are taken as clusters.
69
For category (b) districts, revenue villages and urban wards are combined together to
form the sampling (list) and thirty clusters are selected using the above procedure.
Sample size: To provide district level estimate of reproductive and child health
indicators, RHS-I & II required about 1000 household per district. Considering a
design effect of 1.5, the CATA covers about 1,500 households per district. Each
sample includes (a) 7 households having at least one mother who had a live-birth or
stillbirth during previous 12 months, preceding the date of survey, (b) all married
women in the reproductive age in the all households are interviewed, (c) 7 children in
the age group 12-23 months and 7 children in the age group 24-35 months.
Termination of survey in a cluster: The visit to subsequent households is terminated
after achieving the above numbers. If last selected household has more such member
than needed to reach the target, the information on all such members is collected
before terminating the survey. It is estimated that the above targets will involve a visit
to at least 40-45 households in each cluster. Thus, a minimum of 1200 households are
expected to be covered from each district in one round.
Data management and analysis
Data collection is done on pre-designed questionnaires, which are common for all
participating institutions. Each participating institution is allotted a unique code for
data management. All selected clusters also have a structured location code provided
by the apex-coordinating centre. The data are managed by computers, using a
common data acquisition software, which has been especially developed for this
purpose. This facilitates inbuilt error and inconsistency checks in the data. The district
level analysis is carried out at each centre and sent to apex-coordinating centre in hard
and soft copies. The apex centre pools the data and undertakes final analysis at
regional level. A web based dissemination system is being developed for easy and
quick exchange of information.
Survey Tools.
During the survey, the information is collected at sub-centre, village, household and
individual levels. The set of instrument developed under the project is described
below.
A. Sub Centre Profile: This instrument collects information about
infrastructure available at sub-centre, knowledge and skills of the
ANM, and information on service delivery at subcentre level. This
instrument is administered, if a sub-centre is present in the village,
which have been selected as a cluster. If sub-centre is not present in the
selected cluster/village, then, this section is skipped.
70
B. Village Profile: This instrument collects information on indicators of
villages facilities like distance from pucca road, availability of post
office, bank, local market, health facilities, education, transportation
system and presence of village level institutions, if any. This is
administered in each selected rural cluster.
C. Household Profile: This schedule is administered in all selected
households, starting from the first selected household in the cluster till
the completion of the target irrespective of the fact whether the
household has an eligible member or not. This collects information
about age, gender, marital status, occupation etc. of each member of
the household and socio-economic status, current morbidity and
mortality in the household.
D. Eligible couple profile: This questionnaire is administered to all
currently married females in the reproductive age group, found in the
selected/ visited households. The collected information pertains to age,
education, age at marriage, complete reproductive history child
mortality and current use of family planning methods by the female.
E. Recently Delivered Mothers Profile: This instrument is administered
to seven mothers, who have given a live birth or stillbirth during
preceding 12 months from the date of survey. Information pertaining to
last childbirth is collected, which pertains to antenatal care, delivery
practices, postpartum care, newborn care, etc.
F. Child immunization Profile: This instrument is used for children aged
12-23 months and records status of immunization and related
information like age at which the immunization was given, the service
provider and reason if not immunized.
Indicators being measured
The indicators being measured under the survey include morbidity (in last 15
days), mortality (in last one year), non- Iodised Salt users, fertility (mean number
of children ever bom to women age 40-44 years, total fertility rate, birth order),
current users of family planning methods, unmet family planning need, maternal
health care (ANC check-up, TT injection during pregnancy, IFA tablets during
pregnancy, full ANC, Safe delivery) and child care (percentage babies bathed
immediately after birth, percentage of babies weighed, percentage distribution of
baby weight, percentage of infants discontinued breast feeding at age of 1 to 5
months, immunization status).
*******
71
Annexure-IV
Problems identified (in RCH-I) and mid-course corrections made (in RCH-II)
Mid course correction made during the 10th Plan under RCH-II
Problems
Identified
Programme_________________________________________________
1.
Limited The design process started with national consultation with all states.
involvement of
and The RCH Phase II Program Implementation Plan (PIP) is designed to set out
states
broad strategic direction, define a core minimum service package and
limited
ownership by estimate national resource requirements.
states of
Within this broad evidence-based strategic direction, states will prepare fiveRCH Phase I
year plans linked to clear outcomes after assessing their own priorities,
allowing a needs-based state-specific plan to be developed.
States will be encouraged to form a multi-disciplinary planning team,
involving local stakeholders and resources with a view to prioritizing state
needs.
States have been offered a wide choice of sector reforms and improvements
that they may include in the MoUs to increase accountability and establish
linkages between performance benchmarking and fund flow. States
themselves will plan and select their outcome and process indicators and
reform areas or improvements to achieve the indicators.________________
The core service package is defined and will be included in all state’s plans
for implementation.
2. Pace of
implementatio The MoU will be used as a performance benchmarking/ mutual monitoring
n to be made mechanism and also ensure accountability.
faster
Bottlenecks to fund flows will be removed by simplifying processes.
This has been diagnosed as being due to perceptions of low quality among
the users, frequent service unavailability and low acceptability of some
services.
This will be addressed through pre-service and in-service training, with a
particular focus on provider attitudes and making services more user
friendly.
3. Enhancing
utilization of Contracted staff will be engaged and their performance monitored to ensure
public health continued availability of services.
facilities
The core services will include quality standards.
Demand side stimulation activities will be an important part of state plans.
BCC activities will be focused on improving the image of public health
facilities, promoting new services and improving health- seeking behavior.
Facility norms will be reviewed and altered using multiple criteria to
72
Problems
Identified
Mid course correction made during the 10th Plan under RCH-II
Programme_________________
effectively match needs of users.
The core service package will ensure the availability of essential
infrastructure.
4.
Infrastructure
to
be
Outsourcing will be undertaken with agreed institutional mechanisms to
completed
manage infrastructure and to ensure accountability and delivery of reliable
within
the
and quality services.
project
time
frame
The processes of managing construction of infrastructure will be simplified.
There will be lateral infusion of skilled personnel to improve management
capacity structure at national, state and district levels, with clearly defined
5.
functional responsibilities and roles.
Management
capacity
A system will be established to ensure continuity of tenure of key posts and
positions. States will review the roles of different cadres and restructure them
limited
to strengthen public health and user needs orientation of services as a part of
MoU._______________________________________________________
A study of financial management had been undertaken to identify and
understand the bottlenecks in the current system and design mechanisms to
remove them and simplify the flow of funds. The recommendations of the
study, after suitable validation, have been examined for improved financial
management.
6. Need to
incorporate the
system
of
smooth flow of
funds
The MoUs will clearly define the central government’s responsibilities
regarding the flow of funds and the state governments’ responsibilities on
performance and associated expenditure.
Accounting procedures for reporting and the process of review will be
simplified through an accounting and financial manual which has been
prepared by the center.
Financial management systems will be built into the program management
structure.
Professionals/chartered accountants are being inducted in the area of
financial management.__________________________________________
A clear vision statement has been developed (section 1.1)
7. Need to
have a vision
and
policy
guidelines in
RCH
A strategic plan has been agreed and strategic direction is laid out in the
short, medium and long term (section 1.4).
Strategic objectives and policy options are well articulated (section 1.3).
Outcome indicators have been identified from various policy documents and
commitments at international summits (section 1,2)____________________
8. RCH Phase RCH is visualized as a long-term program oriented towards achieving
I
was ambitious but realistic health outcomes and improvements in CPR and TFR.
implemented
The 5-year period is looked upon as a ‘project’ within this larger time frame
as a project but with definitive outcomes moving towards the long term goals.
without well-
73
Problems
Identified
defined
outcome
indicators.
Mid course correction made during the 10th Plan under RCH-II
Programme
____________________________________________
The national level program framework is the overview, whilst state level
planning will be oriented towards a more limited timescale (5 years) and
linked to specific health outcomes relevant to the state that will cumulatively
lead towards achieving the goals of national health outcomes.
State PIPs will be refined on an ongoing basis as the experience of
implementation and results from studies feed in to the state planning process,
recognizing that state capacity varies widely.
The planning and design will be a dynamic process and the national and state
PIPs, Log Frames and MoUs will be live documents.___________________
States will have different requirements, levels of performance and capacities
and will be able to take these into account when designing their state PIPs.
Such a differential approach may be extended to district level depending
upon the performance of districts.
9. RCH Phase
I had a “one The BCC, though centrally designed, will also be state-specific.
size fits all”
design
The state PIPs will ensure the equitable availability of quality RCH services
designed taking into account the needs of local communities and state
capacities.
Equity issues especially towards the poor and vulnerable will be addressed
through the M&E system and community monitoring.__________________
to RCH Phase II will adopt a program approach, bringing in key elements of
10. Need
'
move:
away sector management and reform and systems strengthening.
“stand
from
alone” public Partnerships with PRIs, ULBs, the private sector, the NACP and the ICDS
program will be built during RCH Phase IL
health
approach
Whilst RCH Phase II necessarily includes supply side strategies, these will
be complimented by an integrated and robust strategy to stimulate demand
for services.
11.RCH Phase
I
focused
almost
exclusively on
the supply side
One part of the demand side strategy will be a comprehensive and
coordinated BCC plan which specifically addresses issues such as the
perceived low quality of services, the availability of services and promoting
health seeking behavior.
A study specially commissioned on the demand supply nexus has been taken
into account in the design.
The family planning initiatives will also be integrated in RCH.
12. RCH Phase RCH Phase II has been designed after wider consultation.
I was centrally BAG states will be assisted in formulating their PIPs.
designed with
MoH&FW accepts that the national PIP is an operational framework.
little
consultation
74
ANNEXURE-V
RCH II TECHNICAL STRATEGIES FOR WOMEN AND CHILD HEALTH
1.1.1
GUIDING PRINCIPLES FOR MATERNAL HEALTH
The following principles will guide the planning and implementation of maternal
health strategies in RCH II:
Equity. The focus would be on the poor and the vulnerable sections of the
society.
• Evidence-base. Interventions included in the program would be evidence
based.
• Continuum of care. The maternal health strategy would be a complementary
mix of community and facility-based interventions.
• Health system approach. Strengthening of health system will be at the core
of maternal health strategy.
• Integrated services. Maternal health interventions will be integrated with
other components of the RCH program, including newborn and child health
and family planning.
•
1.1.2
•
•
•
OBJECTIVES
Improve access to skilled care and emergency obstetric care
Improve coverage and quality of antenatal care
Increase coverage of post-partum care
1.1.3
STRATEGIES
a)
Enhance Coverage of Facilities for Institutional Deliveries and
Emergency Obstetric Care (EmOC)
Expansion and strengthening of facilities for institutional deliveries and
EmOC will be given the highest priority in RCH II. Two levels of institutions
will be targeted, namely, i) PHCs & CHCs for basic EmOC and ii) FRUs for
comprehensive EmOC.
75
b)
Operationalize All CHCs and at Least 50% PHCs for Providing 24 Hour
Delivery Services And Basic EmOC
By 2010, all CHCs and at least 50% of PHCs will be providing 24 hour
delivery services and basic EmOC.
These facilities would also provide services for newborns and children, family
planning,, safe MTP and RTIs/STIs as described in relevant sections.
c)
In RCH I, the strategy of instituting 24 hour delivery services in PHCs was
mooted, but only a few states, such as Tamilnadu and Andhra Pradesh, were
able to implement the scheme at a limited number of PHCs. A UNFPA
project in 7 districts in Rajasthan has demonstrated a rise in met need for
EmOC from 8.8% in 2000 to 14.3% in 2003 (increase of 62%). These
experiences will be built on, replicated and scaled-up nationwide.
d)
Suitable PHCs and non - FRU CHCs will be identified by the state
government. Those with good access, transportation link and some existing
infrastructure would be chosen. Equity consideration will be addressed by
ensuring that underserved areas including the backward, tribal, difficult-toreach ones are well covered.
e)
Infrastructure will be strengthened to an optimum level. Basic equipment for
labor/delivery room and for newborn care will be provided. A newborn care
comer will be developed. Enough supplies of essential drugs would be
ensured. An ambulance (outsourced or otherwise) would be available roundthe-clock for transportation of sick mothers and children to and from
community and referral centers as needed.
f)
Norms and guidelines for these PHCs will be developed. These would
pertain not only to infrastructure, staff, drugs and supplies, but also to
functional standards. A certification system would be instituted. This will
include criteria for criteria for no third delay, gender sensitivity, and
uninterrupted services. The essential criteria would be the availability of
uninterrupted services 24 hours a day, 365 days a year.
g)
The team at PHCs would consist preferably of 2 MOs, who would be
assisted by LHV and nurses for round-the-clock services. Nurses would be
the key functionaries who would provide 24 hour midwifery cover under the
76
supervision of MOs. The CHCs may have specialists in addition. Group D
staff (nurse aid / helper) would also be engaged to provide support for
asepsis, housekeeping and waste disposal. Wherever necessary, staff
including doctors, nurses etc. could be hired on contractual basis. If nurses
are not available, ANMs could be deployed. A laboratory attendant would
be provided for hemoglobin testing, urine examination, blood grouping and
making etiological diagnosis of RTIs/STIs.Training will be provided for
selected skills to each category of the staff as per the training needs
assessment.
h)
Patient care guidelines for care of women, newborn, and children would be
provided. Evidence-based interventions such as use of partogram and active
management of the third stage will be implemented. Suitable job-aids and
manuals will be provided.
[A group will prepare detailed guidelines by October 2004].
1.1.4 Operationalize Comprehensive Emergency Obstetric Services at 2000 First
Referral Units
a) By 2010, a total 2000 FRUs will be made operational to provide
comprehensive EmOC services 24 hours a day, 365 days a year.
b) In RCH II, the unfinished agenda of providing comprehensive
emergency obstetric care services at the sub-district level will be
completed. This would meet the UN norm of one such unit for
5,00,000 population taking also into account the difficult-to-reach and
backward areas. The FRUs will complement facilities in the private
sector.
c) Recently the DoFW has prepared guidelines for Operationalization of
FRUs. States are being approached to develop FRUs accordingly. A
certification process would be instituted to accredit the FURs on the
basis of infrastructure, staff, drugs, supplies, as well as quality of
services.
77
1.1.5 Ensure access to blood bank at all district hospitals and blood storage
facility at FRUs
Blood transfusion is a life saving measure for a woman with hemorrhage and a
anemia.
Provision of blood transfusion is an essential component of
comprehensive EmOC. Hence, it is essential that all FRUs and district hospitals,
have access to blood round the clock. Recently, the DoFW has developed
guidelines for blood storage facilities. This has paved way for establishing blood
storage facilities at FRUs. In addition, it is recommended that each district
hospital has a blood bank or access to one from where blood could be procured in
less than half hour.
1.1.6 Traiii MBBS medical officers in anesthesia for EmOC
DoFW has developed a 14-weeks course an anaesthesia training for MBBS
doctors. The first batch has completed training at ARMS last year.
Administrative formalities have nearly been completed. It is recommended
that by 2010, a total of 4000 MBBS doctors be trained in this course to meet
the acute shortage of anesthetists that has hitherto seriously hampered
Operationalization of FRUs.
1.1.7 Train MBBS doctors in conducting cesarean sections
In view of the non-availability of obstetricians for manning the FRUs, the
FOGSI (Federation of Obstetrics and Gynecological Societies of India) has
developed a course on basic obstetric care including cesarean deliveries for
MBBS doctors. This important step in capacity building in comprehensive
EmOC and operationalisation of FRUs will be implemented in a step-wise
manner. A pilot phase would be followed by evaluation before scaling up.
1.1.8
Provide emergency obstetric care services to BPL families at recognized
private facilities
There is an urgent need to devise mechanisms for BPL families to avail of EmOC
in the private sector. This is extremely important because presently, and for some
more time to come, EmOC in the government sector would not be fully
operational. Yet, in many parts of the country, in cities and towns, a vibrant
private sector is well established. Ways need to be found to provide the poor
access to these facilities. This could be on the basis of a voucher or insurance
system, or by any other innovative method. This issue pertains also to the broader
78
theme of public-private partnership in RCH II dealt with in other sections of the
PIP.
1.1.9
o
o
o
o
o
o
o
Other strategies
Shift specialists (obstetricians/ anaesthetists/ pediatricians) from dispensaries
and PHCs to FRUs and CHCs where they can contribute to emergency care of
women and children.
Involve general surgeons in providing EmOC, wherever possible.
Use telecommunication means (call phones/ emails) for making referral
system efficient.
Provide ambulances at PHCs/CHCs/FRUs (outsourced or otherwise)
Provide incentive to doctors and other staff to work at PHCs/CHCs/FRUs
providing round the clock services. Improve living quarters and working
conditions; recognize good work.
Provide imprest money to ANMs and MOs to run SCs/PHCs/CHCs/FRUs
smoothly (to undertake minor repairs, ensure upkeep of premises at, purchase
drugs/ supplies from market in emergency, hire transport to shift a sick mother
etc.)
Encourage establishment of maternity hospitals / nursing homes in small
towns in private sector.
1.1.10 Behaviour Change Communication and Community Mobilization
Strategies
1.
Janani Suraksha Yojana (JSY)
Janani Suraksha Yojana is the modified version of the National Maternity
Benefit Scheme. Its twin objectives are : a) reduce maternal and infant
mortality through promotion of institutional deliveries, and b) protecting the
female fetus and child. Pregnant women belonging to BPL (below poverty
line) would be eligible. Some of the draft provisions of the JSY include the
following :
a) Pregnant woman who opts for institutional delivery would receive
financial assistance that would be more for the girl child.
b) An assistance of Rs. 1500/- will be provided in the event of a cesarean
delivery.
79
c) A transport assistance of Rs. 150/- will be provided to a rural woman
for travel to a health centre for delivery.
d) The TBA who mobilizes and assists women in antenatal care,
institutional delivery and post-natal care will be provided a financial
compensation.
2.
Provisions have been made to widely disseminate the
information regarding the scheme in the community. The scheme
would help mobilize poor families for skilled care at birth and other
reproductive health services available at government facilities.
3.
Equally importantly, the scheme is also an attempt to reorient
the role of TBAs as agents of change for positive community behaviors
that save pregnant women from morbidity and death.
4.
In RCH II, this demand-side strategy will be vigorously
implemented to enhance utilization of RCH
services at
PHCs/CHHs/FRUs.
1.1.11 Other measures
•
Educate communities about danger signs of pregnancy, labor and post-partum
period. Use media and other IEC/IPC strategies to enable individuals, families
and communities to recognize signs of obstetric emergencies.
•
Launch a sustained social mobilization effort for institutional deliveries with
the help of panchayati raj institutions, opinion leaders, NGOs, self help groups
as well as AWWs, link volunteers, ANMs and other stakeholders; reward
villages that achieve high rates of institutional deliveries, and save mothers
with obstetric emergencies through timely action.
•
Promote referral transport for routine deliveries and emergency obstetric care.
Make referral transport funds available with AWW/ANM. Map facilities; plan
transport options; encourage innovative solutions by communities.
Provide Skilled Care To Pregnant Women At The Community Level
o
Promote deliveries by skilled births attendants at Sub-centres and in
the community
80
o
In some states, many ANMs conduct deliveries at sub-centres and at homes. In
RCH II, efforts will be made to enable more ANMs to provide skilled care in
these settings. States would be encouraged to include sub-centre strengthening
for deliveries as a priority fro their PIPs.
o
A new cadre of Community Skilled Birth Attendants (C-SBAs) is proposed to
be introduced. After a training of one-year, a C-SBA would provide
midwifery care as a ‘practitioner’ in the community. The training of the first
batch of C-SBA is on the anvil. The scheme is, thus, in early stage of pilot
implementation. For the RCH II period, the initiative should be seen as an
experiment - the results of which would decide its future scaling-up.
1.1.12 Permit ANMs to administer obstetric first-aid
ANMs are the front-line workers of the health system in India. Many of them
conduct deliveries in the sub-centre and home settings. All of them are likely
to come across situations when a woman with obstetric emergency such as
post-partum bleeding, eclampsia, or puerperal sepsis would be brought to her
for advice and treatment.
At present, ANM is not permitted to administer injection oxytocin or
misoprestol ( for post-partum bleeding), injection magnesium sulphate (for
eclampsia) or an antibiotics (for puerperal sepsis) that may be life saving even
as she arranges referral of the patient. Lack of mandate to the ANM to
provide obstetric first aid using these drugs is a serious missed opportunity and
a lacuna in the system.
It is therefore strategised that in order to save lives of women with obstetric
emergencies in the community, the ANM is permitted to use the following
drugs:
• Inj. Oxytocin
• Inj. Magnesium sulphate
• Misoprestol oral
• Inj. Ampicillin
It is important to ensure that a systematic training is provided to ANMs prior
to granting permission to use these drugs. Safeguards need to be provided to
ensure that the drugs are administered only after ascertaining the clinical
need. Once the decision is taken to grant right to ANMs to use there drugs
appropriate supplies should be ensured.
81
1.1.13 Improve Coverage and Quality of Antenatal Care (ANC)
Antenatal care is important for not only the mothers but also the newborn.
There is a need to enhance coverage and quality of ANC in the program. The
aim would be to raise the proportion of pregnant women receiving 3 ANC
checks to 80% from the present level of 44% (NFHS II).
1.1.14 Improve equity-driven coverage of ANC
•
•
•
•
Make special efforts to reach women of BPL, SC/ST and other
marginalized groups.
Target primigravida and adolescent mothers.
Ensure fixed - day ANC activity/clinic in the community and the facilities.
Involve AWWs, women’s groups, TBAs and other community partners to
reach out to each pregnant woman, especially the above mentioned groups.
1.1.15 Improve quality of ANC
• Ensure:
o first check up in first trimester
o total 3 check ups or more
o two doses of TT
o ingestion of 100 tablets of IFA
• Ensure that antenatal check includes all the recommended elements
(history, abdominal palpation, BP, looking for edema, urine examination
etc.) at all levels; and, in addition, blood grouping at facility level).
• Improve counseling at ANC sessions focusing on:
o Promotion of institutional deliveries.
o Danger signs of obstetric emergency.
o Birth preparedness: deciding about place and attendant at delivery,
where to go if emergency arises, how would transportation be
arranged, arranging money for emergency situation.
o Early care of the baby, including initiation of breastfeeding, drying
and wrapping, delaying bath etc.
Strengthen skills of ANMs in improving quality of ANC, especially for
counseling.
• Introduce sticks-based rapid estimation of hemoglobin and urine
examination.
82
•
Provide mother-baby linked card to all, depicting key messages apart from
clinical information.
1.1.16 Strengthen Post-partum Care at the Community Level
a)
Post-partum care will be improved significantly in RCH IL It would be
combined with newborn care. The emphasis would be in the home setting.
A large proportion of births, especially among the poor, may continue to
occur at homes. But even the institutionally- delivered mothers and babies
are likely to discharged within a day or so after the delivery.
b)
Home-based newborn care will be combined with home-based post-partum
care.
c)
The IMNCI protocols are being modified to include algorithms and advice
on post-partum care. AWWs would visit neonates and mothers on days
1,2,7,14 and 28 with particular emphasis on the first two visits. They would
use the modified IMNCI charts to identify problems (serious problems such
as puerperal sepsis, and minor problems such a breast conditions), counsel
and refer, if necessary.
d)
Provide mother-baby linked card to all, depicting key messages apart from
clinical information.
The key messages for the mothers would be on:
o Danger signs
o Nutrition
o Iron-folic acid supplementation
o Birth spacing
o Newborn care
1.1.17 STRATEGIES FOR NEWBORN AND CHILD HEALTH IN RCH II
In RCH II, a comprehensive newborn and child health package of interventions will
be implemented in the country with the aim of achieving a decisive breakthrough in
neonatal, infant and child mortality. The knowledge about what saves the lives of
children in a cost-effective manner is available to the nation and the world at large.
The mission in RCHI II is to translate this knowledge into action and usher in the
second child survival revolution in the country.
83
a)
Guiding principles
The following principles will govern the planning and implementation of newborn
and child health strategies:
o
o
Evidence-based interventions
Integrated approach in sync with family planning and maternal health components
o
of the program
Equity-driven implementation and monitoring
Rational mix of family-centered (home level), population centered (outreach) and
o
individual-centered (clinical) interventions
Decentralized priority setting and phasing at the state and district levels
o
Participation of the private sector
o
b)
Newborn and Child Health Strategy: The IMNCI Plus
Objectives of the newborn and child health strategy are:
1. Increase coverage of skilled care at birth for newborns in conjunction with maternal
care
2. Implement, by 2010, a newborn and child health package of preventive, promotive and
curative interventions using a comprehensive IMNCI approach
2.1 At the level of ah
•
Sub-centres
•
Primary health centres
•
Community health centres
•
First referral units
2.2 At the household level in rural and poor periurban settings in at least 250 districts
(through AWWs / LVs)
3. Implement the Medium-term Strategic Plan for the UIP (Universal Immunization
Program)
o
Increase coverage of skilled care at birth for newborns in conjunction with
o
maternal care
Implement by 2010, a newborn and child health package of preventive, promotive
and curative interventions using a comprehensive IMNCI approach at the level of
all Sub-centres, Primary Health Centres, Community Health Centres and First
84
Referral Units as well as at household level in rural and poor periurban settings in
atlest 125 districts (through AWWs/LVs/ASHAs).
o Implement the medium-term strategic plan for the UIP (Universal Immunisation
Programme)
o Strengthen and augment existing services in areas where IMNCI is yet to be
implemented
c)
Why IMNCI ‘Plus’
IMNCI adapted and under early implementation in India takes the generic IMCI
approach much further - by including 0-6 days of age group, by having a health
worker module, and by incorporating the home-based approach for newborn care.
But there is a need to add the inpatient care component for facilities to ensure
effective care of sick neonates and children who require hospitalization. This will be
done by adapting WHO and local guidelines and tools. Even in this comprehensive
form, IMNCI package would still not cover the vital care of the neonates at birth in
home and facility settings. Further, the IMNCI approach includes counseling for
immunization, but the implementation of immunization in India is largely a periodic
outreach activity and that cannot be adequately captured by the IMNCI contacts alone.
Therefore, a comprehensive immunization plan will be an additional pillar of the
newborn and child health strategy. Health system inputs and community level
activities are germane to the effectiveness of not only IMNCI, but also that of care at
birth, as well as successful immunization strategies.
It is in the light of the above reasons that the newborn and child health strategy for
RCH It is named as ‘The IMNCI Plus’ strategy to connote the wider, comprehensive
range of interlinked interventions that form the newborn and child health component
of RCH II program.
d)
Skilled care at birth
This component is linked intimately to maternal care intervention of the program, and
thereby a continuum of antenatal and intrapartum interventions.
The underlying principle of effective care at birth is that wherever an infant is born,
home or facility, she is provided clean care, warmth, resuscitation, and exclusive
breastfeeding. She is weighed and examined, and if her clinical needs are not
manageable at the place of delivery, she is referred and managed at an appropriate
facility. RCH II program aims at promoting institutional deliveries. Newborn care is
85
relatively easy to implement in facilities because of the presence of skilled birth
attendants (doctor/ nurse/ ANM/LHV), and an enabling/ supporting environment.
However, a large proportion of deliveries would continue to occur at homes by the
TBAs for some more years to come, especially in the BAG sates. It is therefore,
considered desirable to continue to impart newborn care skills to TBAs in areas with
high rates of home deliveries, in order to enable them to contribute, as much as
possible, towards newborn survival and health in partnership with the families and the
AWWs/ ANMs/LVs: They will also be provided clean delivery kits. At the same time,
overall effort would be to promote childbirth by skilled attendants and in institutions,
both in the public and private sector.
Skilled care at birth everywhere
Key input
Provider
Level
Institutions*
24 hour functioning PHCs MOs,
nurses
I CHCs
LHVs, Delivery room
Resuscitation equipment
Newborn Care Comer/Unit
Maternity OT & delivery
MOs, specialists, nurses
FRUs, District hospitals
room
Resuscitation equipment
Newborn Care Comer/Unit
Skilled birth attendants
Home
delivery
kit
(wherever
institutional ANMs, nurse practitioners, Clean
Community-SBAs______ Resuscitation equipment
deliveries not possible)
Trained TBAs
(if access to skilled Clean delivery kit
attendants is not possible)
Private institutions should have the same or better norms
e)
ANMs,
IMNCI
The IMNCI approach will be the centre-piece of newborn and child health strategy in
RCHI II. A comprehensive model of IMNCI will be implemented (Fig.4). It would
include the home and community-based component (through ANMs and AWWs/LVs)
and the facility-based outpatient care component, as is being piloted in UNICEF’s
border district project. In addition, a component on management of sick neonates and
children in the inpatient setting at PHCs/ CHCs/ FRUs, and in private facilities will be
added. Health system strengthening and community components will be addressed
effectively to ensure effective implementation.
86
IMNCI implementation at different levels
Level
Approach
Home and Home-based
Communi newborn care
ty
Community
management
of newborn
and childhood
illness
Facility*
Outpatient
care at PHCs,
CHCs, FRUs,
DHs
Inpatient care
at
24-hour
functioning
PHCs, CHCs,
FRUs, DHs
Sites / strategy
Home visits on
day 1,2, 7,14 &
28; more visits
for LBW and
sick babies
Neonates and
children
brought
to
AWW or sub
centre;
and
those seen at
field/home
visits and at
immunization
sessions______
Outpatient care
of neonates and
children
reporting with
illness
Inpatient care
sick
of
neonates and
children
IMNCI
module_____
Basic Health
Worker
(AWW/LV)
module
Provider(s)
AWW/ LV
Supervised
by ANM.
Assisted by
TBA
Basic Health AWW / LV
Worker
ANM
(ANM)
module
Key inputs
IMNCI medications
Referral funds
IMNCI drugs as per
norms
Referral funds
IMNCI drugs
Educational
materials
Observation area
Referral transport
with Newborn
care
Care of sick MO
comer/unit
neonates and nurses/
Inpatient area for
children+
ANMs/
sick children
LHVs
Requisite drugs and
supplies
Referral transport
Physicians’
module
MO; ANM ,
LV, nurses
under
supervision
+Module to be adapted
*To be replicated also at private facilities of corresponding levels
/ developed
It is emphasized that the above strategies will be built on the existing skills of the care
providers, and the existing structures and systems. Several activities and approaches
of RCH I would be continued with enhanced quality and coverage. There will,
however, be significant additionalties to encompass unattended interventions such as
home-based newborn care.
The proposed phasing for coverage of IMNCI is shown in the Table below:
Cumulative operationalization of IMNCI (Suggestive)____________________
By 2009 By 2010
Level_______ Providers By 2006 By 2007 By 2008
75%
100%
30%
50%
Sub-centres /
ANMs
10%
75%
100%
10%
30%
50%
PHCs / CHCs MOs,
/FRUs______ LHVs
100
175
250
Village
AWW
25
50
districts districts
LV
districts districts districts
87
f)
Training for IMNCI
Training load
The tentative number of providers at different levels to be trained are shown in Table
below:
Training for IMNCI: Levels and providers to be targeted (2005-2010)
Providers
Cadre
| Number (approx.)
All sub centres
ANMs
1,30,000
All PHCs
MOs
30,000
All FRUs
MOs
50% PHCs / allFRUs
Nurses
To be determined
ICDS System________
Villages in 250 districts
AWWs
250,000
Private
physicians
To be determined in
consultation
with
states
and
processional bodies.
Level
Health System
Private Sector________
Small towns and villages
88
g)
In-service training
Table below shows outline of in-service training program for different workers.
In-service training for IMNCI and Skilled Care at Birth
duration By whom (suggested)
Content
&
Provider
(tentative)
Health system
(8 days)
ANMs/ LHVs
IMNCI*
Nurses
Care of inborn neonates
Lactation skills
Outpatient and inpatient
care of sick neonates and
children
NIHFW network
Medical
and
nursing
colleges/NNF/TNAI
module
on
(AIIMS
nursing
neonatal
recommended)
(6
MOs
days)_________________
IMNCI
(Newborn
&
young infant module only)
and Inpatient care of sick
neonates
Newborn resuscitation
Inpatient care of sick
children
Lactation/IYCF skills
IMNCI training network
(to be established)
NNF
district
training
system
program
with
improvements
(4+l+l+l=7 days)
ICDS system
AWWs
IMNCI* & lactation and ICDS/NIPCCD network
young
infant feeding
counseling
(8
days)
Private sector
Private physicians
As for the MO
IGNOU
education)
(Distance
TBAs
Clean and safe delivery, NGOs/district centres
home care of neonates
including care at birth,
warmth,
breastfeeding,
small baby care, detection
of danger signs
(3 days)
* Will include post-partum care of mothers
TBAs
89
As far as possible, the training of different providers will be done in such a manner
that a district develops the team at all levels simultaneously. This would ensure
simultaneous operationalization of the entire district health and ICDS system.
The RCH II training workplan is being developed by a core group. The available
training materials and modules are being reviewed. The above outline including the
duration of courses is suggestive, and would be finalized by this group. There will be
an overarching organization/group/ institution to ensure that the quality of training is
ensured for all cadres. The guidelines for this and other organizational issues are
being developed.
h)
Pre-service training
The IMNCI Plus training packages as outlined above for different categories of
workers will be incorporated into the pre-service curricula of physicians, nurses,
ANMs, LHV,s, community skilled birth attendants, AWWs and link volunteers, after
suitable adaptations. The experience gained from the ongoing WHO project on
IMNCI in MBBS curriculum in 5 medical colleges will be built on while planning this
initiative.
Lactation and feeding counseling is also an important area for skills strengthening
among all cadres of health workers/professionals.
The Common Minimum Program calls for expansion of ICDS through out the
country. It is a unique opportunity to train all the new AWWs in the IMNCI skills as a
part of the pre-service training. Likewise, many new ANMs will be trained and
deployed in many states. Hence, IMNCI should become a part of the ANM
curriculum nationally.
1.1.18
Health System Issues
Strengthening facilities for care of newborn infants and children
All PHCs will provide the outpatient level IMNCI. A minimum of 50% PHCs
countrywide (that are being developed into 24 hour delivery institutions) will provide,
in addition: (i) care of inborn neonates, (ii) inpatient care of sick neonates brought
from outside, and (iii) inpatient care of sick infants and children. Suitable norms,
standards and guidelines will be developed, and integrated with those for reproductive
90
and maternal health services at this level. The norms for the facilities will pertain to:
infrastructure, equipment, human resources, drugs/ supplies, referral system, etc.
CHCs and FRUs will be strengthened. Draft guidelines for newborn and child health
services at the CHCs/FRUs have been developed alongwith those for reproductive and
maternal health services. Based on these norms, 2000 FRUs will be operationalized
for providing integrated maternal, child and family planning services in RCH II.
A system of certifying and monitoring the operationlization of facilities will be
implemented. While operationalizing the facilities geographical equity will be borne
in mind to ensure that underserved areas get adequate coverage.
1.1.19 Ensuring referral of sick neonates and children
Referral funds made available with AWW/ANM would be utilized for transport of
sick neonates and children. PHCs, CHCs and FRUs will have ambulances
(outsourced or otherwise) to cater to the referral transport of sick neonates and
children. Communities would be educated about the availability of referral funds/
transport, and BPL/SC/ST families would, in particular be encouraged to avail of
these resources. Community based organizations (PRIs, women’s groups, youth
groups etc.) will be mobilized to innovate local solutions and mechanisms to ensure
transport of sick neonates and children.
1.1.20 Permitting ANMs and AWWs to administer selected antibiotics
To ensure that the life-threatening conditions of sick neonates and children are
managed quickly and effectively, it is of fundamental importance that the providers
closest to the communities have the necessary skills and the mandate to mange these
killer diseases. This is particularly critical for the poorest who cannot seek care away
from homes due to lack of resources.
At present ANMs cannot manage newborn babies with sepsis because they are not
permitted to administer gentamicin injection. And AWWs cannot treat diarrhea or
pneumonia with ORS and co-trimoxazole.
Therefore, the ministry will take steps to ensure that:
o ANMs be permitted to administer injection gentamicin to neonates. The same
would apply to community-SBAs.
91
o AWWs be permitted to administer ORS and cotrimoxazole as per the IMNCI
algorithms. This strategy, would go a long way in improving access to
treatment by critically sick neonates and children, especially those of the
poorest families.
Skills-based training and supportive supervision will be instituted to ensure
acquisition and retention of skills by the workers to administer the specified drugs.
Injection safety norms will be followed strictly for gentamincin injections. Disposable
or AD syringes will be provided.
1.1.21 Other health system issues
The success of IMNCI Plus strategy will depend on the strength and efficiency of the
following ingredients of the health system in addition to those covered above:
Deployment of providers with the desired motivation, commitment and competence
o Strengthening of health infrastructure
o Uninterrupted availability of drugs and supplies
o High quality supervision and monitoring
o Ownership of the state and district level program managers.
o Efficiency of administrative/ financial system
Strengthening neonatal care services and education infrastructure at medical/ nursing
teaching institutions.
Newborn services are often inadequately developed at government teaching
institutions. This hampers training of the medical/ nursing students, and limits the
potential of these institutions to play the desired range or role in training, research and
referral care in the program. Therefore, it is proposed to strengthen newborn and
child health services of medical colleges. Likewise, nursing and ANM schools will be
strengthened to improve their training expertise, capacity and quality.
1.1.22 Community-based Interventions
o BCC and community mobilization are cross-cutting areas in RCH II.
Inputs for ensuring effective demand for and utilization of services for
newborn and child health gains will be systematically woven into the overall
BCC and community mobilization strategy. Following is the outline of key
92
themes that would be promoted through all possible channels and
mechanisms:
o
Mobilize families for institutional deliveries in government/ private
facilities. Launch a sustained social mobilization effort with the help of
panchayati raj institutions, opinion leaders, NGOs, self help groups and other
stakeholders; mobilize communities for Janani Suraksha Yojana.
o
Promote healthy home care practices for newborn care. Promote warmth,
early and exclusive breastfeeding, cord care and hygiene; avoid harmful
practices including early bathing, colostrum discarding, pre-lacteals and cord
applications etc.
o
Promote healthy home practices in diarrhea: Educate families and
communities in: use of home fluids, continuing breast feeding and solid feeds
in diarrhea, for early introduction or ORS to prevent dehydration.
o
Make ORS readily/ freely available. Make ORS packets available with all
primary care providers (AWWs, ANMs, male workers, link volunteers,
teachers etc.) and at all anganwaris, sub centres and facilities (PHCs, FRUs,
CHCs, hospital); use alternative approaches for making ORS readily available
(public distribution system, social marketing).
o
Widen the net of persons who can treat diarrhea. Involve male workers,
community volunteers, and village practitioners among others to treat diarrhea
with ORS.
o
Promote early recognition of neonatal and childhood illness. Educate,
families regarding of signs of sickness (‘danger signs’) among neonates and
children, enable families to seek care early and from trained providers.
o
Improve referral of sick neonates and children who cannot be managed at
home. Educate families, facilitate transport, make referral funds available with
AWWs & ANMs, focus particularly on BPL/SC/ST families.
1.1.23 Other strategies
o
Promote use of the more effective low osmolality ORS as recommended by
WHO
93
o Ensure 100% registration of births as envisaged in the National Population
Policy (2004)
1.1.24 Newborn and child health in urban areas
The principles of newborn and child health services in urban areas would be the same
as outlined above. Because of the unique features of urban setting and the multiplicity
of the actors and agencies, adaptation of the above approaches would be necessary.
While developing the urban RCH component the states are being encouraged to build
on the existing systems to plan most suitable delivery models to take interventions to
the poorest neonates and children.
1.1.25 Promoting care for sick neonates and children of BPL families in private
sector
Private-public participation is being addressed in RCH II design. Options and
mechanisms are being examined to explore how families of BPL families can access
life-saving care for obstetric or pediatric emergency in the private sector. States are
being encouraged to develop innovative approaches towards this objective. The
issues of quality standards and accreditation of facilities that would be compensated
from public funds in lieu of care of BPL mothers/ children are also being examined.
1.1.26 Operations Research
o
o
o
o
o
o
Develop system to monitor cause-specific burden for neonatal and childhood
mortality on population basis.
Develop models of primary care newborn service delivery in rural and
periurban settings.
Assess role micronutrient supplementation in reducing morbidity and
mortality among LBW neonates.
Track burden of low birth weight neonates, and epidemiology thereof.
Undertake surveillance of pneumonia and dysentery-causing bacteria and their
antimicrobial sensitivity.
Access effectiveness of Rotavirus, H. influenzae and Preunmococcal vaccines.
1.1.27 Work in progress
- A detailed action plan for IMNCI Plus strategy is being developed (including
organizational schema, phasing and indicators etc.)
94
- A core group on Training for RCH is engaged in formulating the training action plan
for RCH II.
1.1.28 Infant and young child feeding (IYCF)
Child nutrition is a wide and cross-sectoral issue. RCH II program activities will
complement activities of ICDS and other departments in regard to promotion of
breastfeeding and appropriate complementary feeding practices.
Objective
The objective of RCH II strategy on IYCF will be to contribute towards attainment of
the national goals in nutrition in partnership with the Department of Women and
Child Development and other departments
A National Breastfeeding Partnership has been announced recently in recognition of
the importance of breastfeeding as the crucial child survival intervention.
Following strategies will be implemented:
Implement a nation-wide behavior change effort to promote breastfeeding. Involve all
grassroots workers: TBAs, AWWs, ANMs, village practitioners, male workers, link
volunteers etc.; involve panchayats, self help groups, agents of change, opinion
leaders, NGOs ; employ mass media; use all health-related contacts to promote
improved feeding ; give standard unambiguous messages ( ‘ exclusive breast feeding
for six months’).
Augment AWW’s contacts with mothers. Promote home visiting by AWWs in the
antenatal, and post-natal periods as a part of IMNCI Plus activities.
Use all ANM / male health worker contacts for IYCF counseling. Use immunization
sessions, field visits of ANMs and male health workers for IYCF counseling.
Strengthen breastfeeding promotion efforts at facilities. Promote ten steps of
successful breastfeeding at facilities including PHCs, CHCs, FRUs and district
hospitals.
Improve IYCF counseling skills of providers. Train TBAs, AWWs, ANMs, LHVs,
male workers, link volunteers, as well as physicians (government, private; general,
specialist; modem, ISM) and nurses in lactation and feeding counseling techniques
through pre-service and in-service training and education.
95
Implement the IMS (Infant Milk Substitutes, Feeding Bottles and Infant Food:
regulation, supply and distribution) Act more effectively by educating providers at all
levels about the key provisions of the Act.
Promote appropriate and adequate complementary feeding. Strengthen AWW’s role
through supportive supervision and monitoring, use all health related contacts to
counsel regarding solid foods; emphasize portion size and calorie density; promote
culturally acceptable, low cost, balanced, locally available infant foods (prepare local
lists for counseling).
Launch a National Breastfeeding Partnership with clear mandate, resources,
networking mechanisms and roadmap. The aim is to bring all stakeholders together to
raise the profile of this key agenda in the country and, not only converge their own
programs, but to run a sustained high profile breastfeeding movement in the country
jointly.
*******
96
Annexure VI
Comparative statement on statewise information on the institutional delivery
rates as per the NFHS-III (2005-06) and NFHS-II (1998-99)
Name of the state
Uttar Pradesh
Chhattisgarh
Gujarat______
Maharashtra
Punjab_______
Orissa_______
Andhra Pradesh
Assam_______
Delhi________
Rajasthan_____
Meghalaya
West Bengal
_______ Institutional delivery Rate
NFHS-II (1998NFHS-III (2005-06)
99)
15.2 _________
22.0
13.8 _________
15.7
46.3 _________
54.6
52.6_________
66.1
37.5
_________
52.5
22.6 _________
38.7
49.8 _________
68.6
17.6 _________
22.7
59.1_________
60.7
32.2
21.5_________
17.3 _________
29.7
40.1
43.1
97
Annexure - VII
UNIVERSAL IMMUNIZATION PROGRAMME
ESTIMATED TARGETS AND REPORTED COVERAGE IN PERCENT
1990-91 TO 2005-06_
Coverage levels (%)
Target
(in
lakhs)
Year
Infants
1990- 91
1991- 92
1992- 93
1993- 94
1994- 95
1995- 96
1996- 97
1997- 98
1998- 99
1999- 00
2000- 01
2001- 02
2002- 03
2003- 04
2004- 05
2005- 06*
223.39
233.34
242.90
247.89
247.65
248.61
254.01
255.45
251.17
247.22
240,53
245.24
249.31
256.79
256.26
257.93
DPT
100.72
90.90
90.60
OPV
101.50
91.30
91.00
93.20
93.60
95.20
302.83
94.50
90.70
91.50
92.90
93.70
95.30
102.70
100.80
96.60
91.20
301.79
93.60
303.08
96.90
P. Women
252.66
261.31
270.08
275.55
275.25
275.30
281.08
282.87
277.47
292,41
284.92
272.06
294.46
91.60
92.70
93.90
95.30
95.90
104.10
100.40
97.00
92.50
94.20
95.60
BCG
103.00
92.90
96.60
97.20
99.80
97.10
98.10
99.50
97.70
101.60
108.20
106.10
102.50
100.20
99.90
103.60
MSL TT(PW)
90.90
79.70
77.60
85.00
79.40
85.90
82,60
88.50
87.20
83.80
80.40
82.60
83.20
81.80
82.60
85.80
83.90
88.10
81.30
89.80
86.00
97.00
86.80
93.70
82.90
91.80
77.90
85.60
78.60
90.30
80.20
92.90
Coverage Evaluation Surveys by UNICEF for all
antigens -1998-20005 at All India Level
Year
DPT-3
OPV-3
BCG
Measles
1998- 99
68.6
46.4
68.6
58.8
70.7
61.3
73.2
67.5
72.8
55.2
50.2
55.6
83.4
68.1
1999- 2000
2000- 01
2004-05
63.6
67.3
98
Full
Immunization
51.0
37.8
52.8
54.5
Annexure VIII
District Level Household Survey 2002-04
S.
No.
State
BCG
DPT
3
POLIO
3
Measles
Full
Immunization
Two or
more TT
(preg)
98.4
86.3
51.5
90.4
47.7
86.4
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Andaman & Nicobar
Islands *____________
Andhra Pradesh_____
Arunachal Pradesh
Assam_____________
Bihar______________
Chandigarh_________
Chhatisgarh_________
Dadra & Nagar Haveli *
Daman & Diu *_______
Delhi_______________
Goa________________
Gujarat_____________
Haryana___________
Himachal Pradesh_____
Jammu & Kashmir
Jharkhand_________
Karnataka___________
Kerala______________
Lakshadweep *_______
Madhya Pradesh
Maharashtra_________
Manipur____________
Meghalaya_________
Mizoram___________
Nagaland___________
Orissa______________
Pondicherry *_________
Punjab______________
Rajasthan__________
Sikkim______________
Tamil Nadu__________
Tripura
92.5
56.1
62.7
46.8
89.9
87.8
95.7
94.0
90.9
96.6
86.6
83.3
96.1
94.6
52.0
92.5
98.0
99.7
72.6
95.9
83.4
64.9
79.0
67.7
88.5
99.3
88.0
60.6
91.4
99.0
75.0
78.7
36.0
39.5
35.0
78.6
70.5
92.1
77.7
71.1
87.7
68,9
75.7
91.2
48.1
39.3
84.5
90.7
86.9
43.9
88.5
48.8
31.2
48.7
32.5
70.0
93.8
82.8
36.4
74.0
96.8
47.9
82.2
32.1
30.0
34.3
62.8
70.6
92.1
67.6
71.9
87.9
71.2
75.0
86.5
55.9
38.4
83.7
89.6
74.5
47.2
82.3
50.6
26.1
46.1
26.7
69.3
94.8
82.7
36.8
60.0
95.5
35.2
74.4
39.3
39.1
28.2
79.0
70.2
87.0
78.6
76.4
93.1
69.4
69.2
89.7
83.0
34.5
80.4
90.0
91.8
50.1
88.0
55.6
30.3
61.6
40.2
69.9
95.8
79.1
36.8
82.6
95.7
44.7
62.9
22.5
19.3
24.4
53.3
60.9
85.2
57.3
61.0
81.5
57.7
62.9
79.4
38.6
29.3
74.1
81.2
67.6
32.5
74.3
37.0
14.1
35.3
14.4
55.1
89.4
75.3
25.4
50.2
92.1
26.7
84.5
43.6
57.6
71.0
64.0
67.8
84.1
81.1
75.0
76.2
73.2
77.5
58.1
73.6
64.2
79.5
87.5
89.3
64.5
79.4
67.6
30.3
47.8
43.5
76.6
97.2
84.4
59.1
77.5
86.3
68.3
33
Uttar Pradesh
57.8
37.9
36.9
37.7
28.1
61.5
34
35
Uttaranchal_________
West Bengal_________
INDIA
72.8
86.4
74.7
57.7
69.8
59.0
57.3
67.0
58.2
56.9
67.6
58.0
47,2
54.4
47.6
64.4
86.2
71.8
1
99
Annex-IX (a)
S.No.
1.
v
T
y
y
y
y
y
y
tt
y
y
y
y
y
y
y
y
y
2L
y
23?
y
25?
Distribution and annual intake in the MBBS course in medical colleges
Annual Intake
No. of colleges
State
Andhra Pradesh
Assam
Bihar
___
Chandigarh
Chhattisgarh
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu & Kashmir
Jharkhand
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Orissa
Pondicherry
Punjab
Rajasthan
Tamil Nadu
Uttar Pradesh
Uttaranchal
West Bengal
Total
Govt.
9
3
6
1
1
4
1
8
1
2
2
3
4
5
5
18
3
1
3
6
11
9
Other
5
2
2
100
4
1
10
1
2
2
T
T
18
1
22
17
1
2
3
7
113
Total
14
3
8
1
T
5
35
1
3
3
6
6
16
5
2
1
y
T
61
174
1975
391
510
50
100
460
100
1405
150
115
350
190
2955
800
620
4010
100
364
275
520
650
1865
1212
100
905
20172
Annexure -IX (b)
Annual Intake in the specialties related to maternal care
S.
No.
State
MD
(OBG)
MS(Gen.
Surgery)
MD (Anes
thesiology)
Diploma
in Anes
thesia
1.
Andhra Pradesh
Assam
Bihar
Chandigarh
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu & Kashmir
Jharkhand
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Orissa
Pondicherry
Punjab
Rajasthan
Tamilnadu
Uttar Pradesh
Uttaranchal
West Bengal
Total
55
16
9
1
24
4
68
9
5
76
20
30
7
28
4
78
49
7
11
3
23
3
81
5
2
51
12
8
H
3.
4.
5.
6.
7.
T"
9.
10
11.
TT
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
9
86
17
16
102
6
12
10
39
24
33
555
101
4
28
12
141
42
53
137
8
26
8
40
742
79
71
18
18
93
3
T
6
61
1
480
10
4
H
T"
3
6
2
110
12
19
70
4
~4~
23
6
62
17
3
24
493
Annexure-X (a)
Number of Nursing Education Institutions as on 31st March, 2004
si.
NO.
States and
Union
Territory
1 Andhra
Pradesh
2. Assam____
2 Bihar_____
Chattisgarh
5_ Delhi
2 Gujarat
2 Haryana
8 Himachal
Pradesh
9 Jharkhand*
10 Karnataka
11 Kerala____
12 Mahakoshal
13 Maharashtra
14 Mizoram
15 Orissa_____
16 Punjab
17 Rajasthan
18 Tamil Nadu
19 Tripura
20 UP
&Uttarachal
21 West Bengal
22 Chandigarh
23 MIB______
24 SIB_______
25 AFMS
TOTAL
±
Registered nurses in
respective State Nursing
Registered Council
A.N.M. G.N.M. DNEA B SC. P.B. M.Sc(N) Short M. PhD A.N.M. G.N.M. HV/FHA
Term Phil
(N) B.SC(N)
2480
94395 84306
22
39
1
91
Total No. of Nursing Educational Institutions in India
recognized by INC
9
23
2
2
2
i
12
13
2
12
18
12
5
1
2
2
1
5
2
1
1
1
1
30
154
74
16
47
3
4
55
38
54
1
24
16
22
1
12
7
16
1
15
27
8
8
2
3
214
4
17
6
684
2
2
i
5
15
1
1
1
67
5
7
2
1
15
1
3
5
11
2
36
1
5
2
1
2
1
i
1
1
2
1
2
187
38
34
1
2
12
1
1
1
5
2
1
12589
7501
93
355
35840
13112
9087
10321
8883
179
2594
85796
15821
7920
15
47407
27612
25344
25690
1441
30213
17389
22239
52819
969
26956
10
54762
71589
92331
81983
1301
46090
43470
35482
159525
641
17479
110
2584
850
11083
79
2763
55858
44652
11294
506924 865135
50393
511
1352
694
411
6836
7797
998
551
* Registration Started from August 2004
ANM: Auxiliary Nurse Midwives
Assam = Assam+Arunachal Pradesh+
Manipur+Meghalaya+Nagaland
Maharashtra = Maharashtra+Goa
Punjab = Punjab+J & K
GNM: General Nursing and Midwives
DNEA: Diploma in Nursing Education
and Administration________________
B.Sc(N): Bachelor in Nursing,
Tamil Nadu = Tamil Nadu + Andaman
& Nicobar Islands + Pondicherry____
West Bengal = West Bengal+ Sikkim
M.Sc(N): Master in Nursing
PBBSc.(N): Post Basic Bachlor in
Nursing
102
Annexure-X (b)
Distribution of Nursing Educational Institutions Recognized by India Nursing
Council [ as on 31st March, 2006]
S-No.
1 Andaman & Nicobar
2 (Andhra Pradesh
3 [Arunachal Pradesh
[Assam___________
■ ~ j5 jBihar
'______
6 [Chandigarh
_ 7 jchattisgarh_______
8 HPelhi
__ „
™9
__
Goa
___
23
24
| 25
26
I 27
~~28
(Orissa
31
32
_____
[Pondicherry_____
[Punjab
[Rajasthan________
[Sikkim
___ _
iTamilnadu
r~29 "~]rripura
27
1
1 ~
____
__ ______
11 Haryana
12 jHimachal Pradesh
| 13 jjharidiand________
14 pammu & Kashmir
15 [Karnataka
[" "16 [kerala
17 [Madhya Pradesh
18 [Maharashtra
19 Manipur
20 [Meghalaya_______
I_ zi
21 Mizoram________
22 [Nagaland.. ..........
i
A.N.M.
1
30
1
3
10
2
' 3 ~
1
4
14_
13
22
3
2
2
1
16
1
34
10
... 0__
.i.~
30 [Uttar Pradesh_____~ 30
[Uttaranchal
0
[West Bengal_____
20
Grand Total
271.
C.N.M.
1
182
2 _
11
15
0
1
17
2
28_
25
6
2
2" '
~ 392
^!37^
24
71
4
5
4
1__
20
1
92
74
0
102
3
50
0
38
1312
103
B.Sc.
0
107
0
M.Sc.
0
2
0
P.B. B.Sc.
0
1
"T.
o
.6
o
L
...0 .
0
1
___0
2
1
9
5
2
5
3
0 “
0
0
237
59
23 ~~
23
0
1
2
0
8
5
J9
5~"~
1
49
0 ~
6
2
5
580
i
2
0
1
0
0
0
0
~ 25
3
3
2
0
0
0
0
0
~ 0
2
0
0
33
0
0
0
2
11.
0___
0
0 ~
0
22
5
4___
6
__ 0
0
~ 0
0
1
0
6
....
0
9 _
0
1
0
2
62
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