SECOND COMMON REVIEW MISSION
Item
- Title
- SECOND COMMON REVIEW MISSION
- extracted text
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m i (mi nnniin review iiissiox
November - December 2008
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NATIONAL RURAL HEALTH MISSION
Ministry of Health & Family Welfare
Government of India
Nirman Bhawan,
New Delhi-110001
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Contents
Page No.
Title
1.
Executive Summary
2.
Report of the Second Common Review Mission
1
3.
Findings of The Common Review Mission
9
4.
Recommendations of the Second Common Review Mission
43
5.
Key Issues across the states - A summary
48
6.
Summary Reports of findings from each state
90
Abbreviations
ANC
Ante-Natal Care
ANM
Auxiliary Nurse Midwife
ASHA
Accredited Social Health Activist
AYUSH
Ayurveda, Yoga, Unani, Siddha, Homeopathy
BPM
Block Programme Manager
CHC
Community Health Centre
CMHO
Chief Medical and Health Officer
CRM
Common Review Mission
DH
District Hospital
DHAP
District Health Action Plan
DHS
District Health Society/Director Health Services
DOTS
Direct Observation Therapy - Short-course
DPM
District Programme Manager
EDL
Essential Drug List
EmOC
Emergency Obstetric Care
EMRI
Emergency Medicine and Research Institute
FRU
First Referral Unit
FW
Family Welfare
GOI
Government of India
Hb
Haemoglobin
HMIS
Health Management Information System
ICDS
Integrated Child Development Scheme
IDSP
Integrated Disease Surveillance Project
IMNCI
Integrated Management of Neonatal and Childhood Illnesses
IMR
Infant Mortality Rate
IPHS
Indian Public Health Standards
IT
Information Technology
JNU
Jawaharlal Nehru University
JSY
Janani Suraksha Yojana
LHV
Lady Health Visitor
LLFS
Life-Line Fluid Store
LT
Laboratory Technician
MCHN
Maternal and Child Health, and Nutrition
MMR
Maternal Mortality Rate/Ratio
MMU
Mobile Medical Unit
MNGO
Mother NGO
MO
Medical Officer
MOHFW
Ministry of Health & Family Welfare
NCD
Non-Communicable Diseases
NDCP
National Disease Control Programmes
NFHS
National Family Health Survey
NGO
Non-Government Organisation
NHSRC
National Health Systems Resource Centre
NIPI
Norway-India Partnership Initiative
NRHM
National Rural Health Mission
OPD
Out Patient Department
PHC
Primary Health Centre
PIP
Programme Implementation Plan
PIU
Programme Implementation Unit
PMU
Programme Management Unit
PPP
Public Private Partnership
PRI
Panchayati Raj Institution
PTS
Pregnancy Tracking System
RCH
Reproductive and Child Health
RDK
Rapid Diagnostic Kit
RKS
Rogi kalyan samiti
RMRS
Rajasthan Medicare Relief Society
RNTCP
Revised National Tuberculosis Control Programme
RSBY
Rashtriya Swasthya Bima Yojana
SC
Scheduled Castes
SDH
Sub Divisional Hospital
SDP
State (Gross) Domestic Product
SHC
Sub Health Centre
SHRC
State Health Resource Centre
SHSRC
State Health Systems Resource Centre
SIHFW
State Institute of Health and Family Welfare
SPMU
State Programme Management Unit
SRS
Sample Registration Systems
TFR
Total Fertility Rate
TSP
Tribal Sub Plan
TT
Tetanus Toxoid
UC
Utilisation Certificate
VHND
Village Health and Nutrition Day
VHSC
Village Health and Sanitation Committee
Executive Summary
Executive Summary
The Second Common Review Mission of the National Rural Health Mission was held in
November- December of 2008, 43 months after the formal launch of the programme and 27
months after the Framework for Implementation was approved by the government. Eighteen
officials of the central and state government, 19 public health professionals from academic
and technical institutions and 17 public health activists from civil society and 13
representatives of development partners, a total of 67 persons, participated in the mission.
The Mission divided into 13 teams which visited over ten facilities in a minimum of two
districts in 13 states. And at each of these sites, the Mission interacted extensively with
community representatives, service providers, and officials and then after discussion with
state officials submitted their state reports. These state reports have been summarized in
this national report along with an analysis of general trends across states.
The Mission studied changes across 19 parameters. In this report we sum these findings up
into four main headings. The most important of these is improvement in service delivery and
facility functionality leading to a notion of fully functional facilities that deliver on the NRHM
promise of service guarantees. The other headings are human resource development,
improvements in management and strengthening of community processes.
Key Findings of the Mission:
1. The most important finding is a general increase in utilization of
public health
services, reflected in increased outpatients, increased in-patients and a sharp
increase in institutional deliveries and greater utilization of ancillary services like
diagnostics, referral transport etc. This increase is seen across states. Though
Janani Suraksha Yojana is a major driver of this increase, other factors like more
nurses and doctors put in place, better availability of drugs and improved cleanliness
and above all the increasing will to revive public health systems are becoming the
dominant contributing factors.
The increased utilization is not uniform across all facilities in all states. In six states, all of
them high focus, despite an overall increase, the increase at the 1 per 30,000 PHC level is
modest or absent. And in a few of these six states increases in service even at the sub
center level have been compromised by the focus on developing the 1 per 1 lakh CMC (or
block PHC). This has occurred because of a conscious policy to optimally utilize scarce
human resources by pooling them to viable levels at few centers, rather than spreading them
thinly. Or this has occurred because of core sub-
center services being transferred to higher levels, with little plans forthose who are still
unable to access the higher health facility. In most of these states with secondary
centers now overcrowded and reeling under the pressure of institutional deliveries,
attention to revitalizing the primary health center is drawing more attention.
3. All states have seen substantial increase in numbers of service providers deployed.
There is now an increased awareness of sub-critical densities of human resource in
the public health system, a legacy inherited from the nineties, as one of the critical
reasons for the poor performance of public health systems. Along with this some
states have substantially revised and improved on key dimensions of their workforce
management policies whereas other states, though seized of the issues, have yet to
push through the minimum necessary changes for ensuring a motivated workforce
from whom performance can be demanded. One important development is a range of
incentives across states to improve availability of the workforce in hitherto underserved
areas. There is concern that the major part of the increases are contractual and
sustainability beyond the sanctioned NRHM period would be a problem especially
where states have not fully owned the essential nature of such expansion and planned
for it in state budgets.
4. Expansion of paramedical, nursing and medical education is occurring in all states and
there are plans for a major acceleration of this. Lack of faculty, lack of institutions and
lack of resources seriously hamper this expansion. In many states almost all
recruitable staff available on the open market have been taken in- and unless the pool
of new recruits is sharply increased further improvements even in service delivery
would become critical. This is most important in the poorest performing states where
existing human resource density is extremely low, and all these NRHM driven
increases have not been enough to even catch up with the pre- NRHM levels of
human resource availability in the high performing states.
5. Quality of care and preparedness of facilities have improved. However states with
better baselines like Kerala, Tamil Nadu and Maharashtra have been in a position to
make quicker use of untied funds and the state and district planning process for
addressing these issues. Though there has been significant improvements in
infrastructure, drugs, diagnostics, sanitation and hygiene , dietary arrangements etc in
the high focus states the rapid increase in utilization, especially the rise of institutional
deliveries tends to
outpace the relatively much slower rate of expansion of
infrastructure, human resource and supplies. Addressing this would require even more
flexibility in funding along with better management arrangements at the state and
district level.
6. Induction of management skills, IT skills and accounting skills in a major way into
every state and district level has improved the management of programme
significantly. Fund flows have increased with computerization of accounting and bank
transfers of funds at most levels. However states have shown very varied progress in
setting up institutions that are needed to improve management and drive the process
of architectural correction. This is particularly a problem in the area of procurement
and logistics (where TNMSC is a national benchmark), in infrastructure development
(where the Gujarat Pill is a benchmark) and in the area of technical assistance (the
planned SHSRCs) and in the area of training institutions (the SIHFW equivalents and
the pyramid of institutions below them).
7. ASHA programme has expanded on the ground to cover all the high focus states
except Himachal Pradesh and Jammu and Kashmir, and is now being expanded to
cover the entire nation. The ASHA has emerged as an enthusiastic community health
worker whose effectiveness and live contact with the public health system is sustained
through the JSY and her role in the village health and nutrition day/immunization
session. Most states are working on improving their support systems, improving the
quality and frequency of training, regularizing payments, refilling drug kits, providing for
special referral support and expanding the incentive package. As these steps come
into place the programme can be expected to pick up and provide a much higher level
of outcomes. Most other dimensions of community participation- the village health and
sanitation committee, the community monitoring programme, the public participation in
rogi kalyan samiti and district health societies are showing good potential but in many
states it is too early to comment as they are only in the take-off stage. There is scope
to increase NGO participation in the ASHA programme and in strengthening other
community processes.
8. Systemic inadequacies are affecting all vertical programmes, the most important of
these being the poor densities of functional health facilities and consequent low human
resource densities in the low performing states. In addition immunization continues to
be affected by poor logistics. The efforts at integration, especially by using the district
plan process to address systems - programme linkages could be strengthened.
9. Most planning for fully functional facilities or achieving IPHS norms focus on the RCH
components. Other health care needs like management of acute illness, so critical to
disease control programmes, of trauma, and of non communicable disease are not as
yet getting the importance due to them in planning, in resource allocation, in human
resource planning or in monitoring. There is a need for high performing states to show
the way forward in these areas. There is a need for these states to develop models of
integration of these concerns, that could represent upto 80% of morbidities, into the
district plan.
10. Hospital Development Societies are in place in all district, divisional and block
hospitals and in most PHCs. These societies are functional and are an effective
vehicle for untied funds and to some extent of improved facility level management and
this has substantially contributed to improving quality of services. Much needs to be
done however to make them more conscious of their role in safeguarding equity ,
along with quality of services, and to reduce their image as merely being a vehicle for
user fees. The problems of user fees are poorly appreciated by both facility level
service providers and these societies. However problems like lack of exemptions for
the poor, non utilization of certain services, exclusions are present and were evident to
the visiting mission teams..
11. Decentralisation in terms of devolution of governance powers to panachyats continues
to be a challenge. However progress has been made on involving panchayats in the
structures of the mission - VHSCs, hospital development committees and in district
health societies. Capacities for district planning have improved substantially but the
process is hampered by lack of information about the resource envelope available
against which the district plan is made and a failure of states to release moneys to
districts according to the approved district plan and to use the district plan as the
instrument of programme review.
12. A wide variety of non governmental partners have been involved in provision of
services or strengthening of the programmes. For the large part they are not-for-profit
agencies who are reaching out to underserved areas through different contracting
arrangements. In a few states like Bihar there is outsourcing of ancillary hospital
services to local agencies and individuals against a standardized agreement. Though
these are all useful supplements to the public health system there is no generally
replicable model that has been seen in the states visited. In all cases of partnership,
even where it is a reputable not- for-profit group involved, there is a need to have an
independent monitoring mechanism in place, and careful assessment and construction
of financing arrangements so that services are appropriately budgeted and sustainable
and for all of this there needs to be sufficient district and state capacity.
Recommendations:
1. Work with states to finalise a clear nomenclature for the different facility levels and
their hierarchical relationships to each other. This is a major constraint in planning,
financing and monitoring.
2. Work with states to contextualize IPHS guidelines so as to be able to plan and set
meaningful annual targets for improvement in a phased approach to reach the goal at
every facility level. Also to contextualize so that service priorities under IPHS reflect
the epidemiological profile in each state.
3. Renew attention on strengthening the PHC. In most states this would be based on
achieving the IPHS norms in human resources for PHCs, but in states with a human
resource crunch, alternative human resource management strategies based on multi
skilled paramedics would be needed.
4. Improving the quality of care and comfort of stay for the in-patients in the public
hospitals especially at the secondary level, through clean toilets, fresh linen, and a
friendly environment. Over time move to a system of ensuring quality improvement in
all public health facilities.
5. Mainstreaming AYUSH not merely mainstreaming the AYUSH provider: Provide users
with a greater choice of services by having the AYUSH service provider, and not use
them as additional allopathic curative care providers.
6. Where an AYUSH doctor is being used as a substitute to a MBBS medical officer,
there is a need to specify through standard protocols the level of care that can be
provided by them and provide them with the training and legal framework to provide
such care.
7. There is a need to urgently strengthen the ASHA support system. This includes a state
level resource team capable of developing further state specific material needed and
well trained and supported district and block level teams of facilitators and a system of
monitoring. Streamlining of payments also needs to be strengthened and its base
widened by allowing a larger number of activities to be incentivized.
8. Enhance community participation, especially representatives of user groups in the
hospital development committees (rogi kalyan samitis), and transform their image from
being a vehicle of user fee collection into an organization charged with addressing
equity and quality issues.
9. Activise the formation of village health and sanitation committees and strengthen
facilitation systems for this. In particular NGOs could play a major role in this.
10. Simplify the current process of community monitoring and broad base the programme
participants and expand on it.
11. Improve coordination between the health mission and the directorates in the states
and increase training and support inputs to directorate staff so that they are able to
fl
participate and eventually lead in the process of change and revitalization of public
health systems.
12. Work with state governments to start up 3 management organizations/ arrangements
of minimum design specifications immediately - one of these being for procurement
and logistics, another for infrastructure and the third for technical assistance (the
SHSRCs).
13. Improve the quality of public health management through the development of a public
health sector management cadre, expansion of public health education including in
service skill training and improved human resource development policies for health
administrators.
14. Make improvement of workforce management policies one of the cornerstones of good
governance in the states and support states to move to evolve and implement
commonly agreed to policies in this regard.
15. Assist and support states to draw up and implement plans to revitalize their SIHFWs or
equivalent organization and other training institutions in the states so as to ensure that
in-service skill upgradation meets the quality and pace required to improve service
delivery.
16. Assist and support states to draw up and implement state specific human resource
development plans to expand with quality medical, nursing and paramedical education,
such that the needs of the public health system are prioritized and met within the
shortest time possible.
17. Build a national plan linked to the above to take on the responsibility of developing
faculty and quality assurance systems for this rapid expansion in medical, nursing and
paramedical education.
18. State spending on human resource component should expand, so as to slowly take in
the new positions being created under NRHM. This is essential for sustainability, for
better work force performance and as part of states commitment to increased public
health expenditure. A wider and innovative set of incentives must be tried out and then
institutionalized for attracting and retaining skilled personnel in difficult areas.
19. Link district plans to resource envelopes available for districts and also develop the
practice of revising the plan document after sanction and based fund allocation and
review on this.
20. Develop the district plans further so that this is used to rationalize, infrastructure and
human resource and financial resource deployment to match utilization patterns of
different facilities and areas.
21. There is a need to ensure, that there is a proportionate allocation and expenditure of
funds for accelerating non JSY dimensions of RCH that would prepare the facilities to
deliver quality services as well as address all issues of women’s health. In parallel the
facilities need to be prepared for addressing neonatal care and meeting felt needs of
contraception.
22. The NRHM’s emphasis on human resource development should take the needs of the
disease control programmes into account. Even in key district level management
positions there are shortages of staff. Integration of disease control programmes and
IDSP in the district plan in a technically meaningful manner is essential for improved
outcomes in many programme, but especially in vector control.
23. While immunisation programmes have been given attention in states with regards to
outreach and fixed day immunization services, gaps in availability of vaccines and
issues in cold chain management seem to have adversely affected progress in the
current year.
24. Progress beyond planning for RCH service delivery in primary and secondary facilities
to plan for addressing emergencies, acute illness and even chronic illness into primary
and secondary health care and through the development of appropriate referral
linkages and human resource development and deployment strategies such that all the
facilities within a district become like parts of a single functional unit. High performing
states on RCH parameters should take the lead on this.
25. Improve the flexibility of fund allocation to facilities within a district and to districts
within a state so that funds flow to facilities and districts which use them best. This is
essential to expedite useful absorption of funds. However funds needed to reach a
minimum level of functioning and equity considerations within regions are kept in mindso that places already suffering for lack of human resources and sanctioned facilities
are not deprived even further.
26. Engage with the private sector to provide services in thematic and geographic areas
where the public system is deficient working out packages that are cost effective and
transparent and subject to good monitoring practices.
27. Develop HMIS systems and capacities so that action can be taken on information
derived from data analysis at the facility and at the sector, block and district level. The
main challenge is the development of district level systems and capacities for use of
information. The other major challenge is to be able to collect information from the
private sector as well.
Report of the
Second Common Review Mission
The Second Common Review Mission Report
Background
The National Rural Health Mission (NRHM) was launched on 12th April 2005, to provide
accessible, affordable and accountable quality health services that would reach even the
poorest households in the remotest rural regions. The detailed Framework for Implementation
that defined the strategy by which this goal would be approached was approved by the Union
Cabinet in July 2006. This Common Review Mission, the second one, is an assessment of the
progress during the last year that have since elapsed. To put greater emphasis on the states
with the more unsatisfactory health indicators, 18 states were classified as special focus
States. 1 This Common Review Mission covers 9 of these 18 states and 4 of the other 11
states.
The National Rural Health Mission represents a major departure from the past, in that central
government health financing is now directed to the development of state health systems rather
than being confined to a select number of national health programmes. There are many
considerations behind such a shift. This shift is important for improving the structure and
functioning of public health systems because all national health programmes taken together
account for only a small part of morbidities - in the range of about 20 to 30%. Another reason
for this shift Is because investment in health systems development is essential for good results
even for national disease control and RCH programmes. For investment in health funding to
impact on health equity and on poverty, larger funds have to flow for health systems to those
very states whose ability to raise resources internally are most limited and who have a greater
burden of poverty and inequity and, therefore, a greater burden of disease to bear. While the
state governments bear the responsibility of planning and providing the health services in their
state, the NRHM is expected to facilitate health systems strengthening and infuse new energy
through this support from the centre.
The NRHM framework represents a conscious decision to strengthen public health systems
and the role of the state as health care provider. The NRHM also recognises the need to
make optimal use of the non-governmental sector to strengthen public health systems and
increase access to medical care for the poor. There has been concern on whether such an
approach is pragmatic given the poor record of performance of the public health systems. The
NRHM framework is built on an understanding that low and declining public investment in
1 The high focus states are the 8 states of the North-east- Assam, Sikkim, Tripura, Meghalaya, Mizoram, Manipur, Nagaland and Arunachal
Pradesh the eight low performing states of Bihar, Madhya Pradesh, Uttar Pradesh, Rajasthan, Orissa, Jharkhand, Chhattisgarh, and
Uttaranchal; and the two states of Jammu and Kashmir and Himachal Pradesh. The NRHM is also being implemented in the remaining 'nonhigh-focus states"-.
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health care and the many structural problems in the way the public health systems have been
organised are the main reasons why the public health system has been functioning poorly and
this must be addressed through increased public expenditure and through architectural
correction of the public health system. Given the uneven growth of the private sector, its
current situation in terms of regulation of quality and pricing of services as well as the issues
of access to the poor, the public health care provider remains the mainstay of public health
policy.
The NRHM is, therefore, about increasing public expenditure on health care from the current
0.9% of the GDP to 2 to 3% of the GDP in an effective manner so as to strengthen the public
health services. The corollaries of such a policy directive are not only an increased central
government budgetary outlay for health, but that the states also make a matching increase -
at least 10% of the budget annually, including a 15% contribution into the NRHM plan, and
that the center-state financing ratio shifts from the current 20:80 to at least a 40:60 ratio in this
plan period. Another important corollary is that the state health sector develops the capacities
to absorb such fund flows. This is why a process of reforming and strengthening the state
health systems needs to go hand in hand with the increase of fund flows.
The other core objective of the NRHM, which is also central to reviving trust in the public
health system, is the responsibility of creating what the framework calls, “fully functional health
facilities” within the public health system. Whether it is a sub-centre, or a PHC, a CHC or a
district hospital, the NRHM framework spells out a service guarantee expected of that level,
and promises to provide the resources and assistance needed by states to close that gap.
The outcome most expected from the Mission is that each facility is able to fulfill this
guarantee.
The “architectural correction” of the public health system envisaged by the NRHM, so as to
deliver on these two core objectives that would lead to the goal of “equitable, affordable,
effective, quality health care”, is organised around five pillars, each of which is made up of a
number of overlapping core strategies.
a) Setting Norms and Standards and Achieving Service Guarantees: The first of
these pillars is the setting of norms and standards for public service health delivery
which match the notion of service guarantee outcomes and putting in place a
mechanism of monitoring and support to ensure that this is reached. Once the norms
and standards are in place the challenge is of identifying in a facility specific manner,
the gaps in infrastructure, human resource, equipment, drugs and supplies and above
all in service outcomes. And then the challenge becomes to ensure that states are
seized of this task and have built roadmaps to close these gaps and are traversing
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down these roadmaps they have set themselves. Gaps in infrastructure require an
efficient mechanism of completing civil works in time with quality. Gaps in equipment
are relatively easily addressed. Gaps in drug supplies need an adequate drug
procurement and distribution system. Gaps in human resource require expansion of
education plus workforce reforms and innovations. The NRHM has put in place the set
of Indian Public Health Standards for each of the facilities from Sub-centre to District
Hospital with service guarantees at each level. Most states have completed facility
surveys and identified their gaps and are seized with the task of closing these gaps.
The Common Review Mission Itself represents the apex of a pyramid of monitoring
and evaluation strategies meant to assess and ensure movement on this path to attain
the fully functional health facility. In addition the NRHM framework assures the states
that the center would contribute substantially to the financial and the technical
resources needed for states to close this gap.
b) Innovations in human resources development for the health sector: The central
challenge of the NRHM is to find definitive answers to the old questions about ensuring
adequate recruitment and retention for the public health system and adequate
functionality of those recruited. Breaking a vicious cycle where poor performance of
the workforce has justified poor attention to solving the fundamental problems of
human resource development, the NRHM lays downs a minimum human resource
requirement for each facility level and follows up to ensure that states agree to a
roadmap to close these gaps. The most important outcome of this is the dramatic
increase in the number of nursing and allied staff being brought into the system. The
contractual appointments route and local recruitments to immediately fill gaps as well
as ensure local residency, incentives for staff working in hitherto underserved areas,
and the use of multi-skilling and multi-tasking options are examples of innovations that
seek to find new solutions to old problems. Expansion of professional and technical
education and increasing access of weaker sections to such education are also a core
strategy.
c) Increasing Participation and Ownership by the Community (also referred to as
communitisation): This is sought to be achieved through an increased role for PRIs,
through the ASHA programme, through the village health and sanitation committee,
and through increased public participation in hospital development/management
committees. The district health societies, the district and village health planning efforts,
the special community monitoring initiative, and the greater space for NGO
participation are also envisaged to contribute to enhancing inclusions of community
perspectives in decision making.
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d) Improved Management Capacity: The approach adopted is of professionalising
management by building up management and public health skills in the existing
workforce, supplemented by inculcation of management personnel into the system.
Another major component of this is the creation of institutional capacities for improved
management in the form of functional programme management units, strengthened
directorates of health services, strengthened and outcome oriented state institutes of
health and family welfare that ensure that the workforce in every facility has the
necessary skills to deliver its service guarantees, and the creation of state health
resource centres that act as strategic planning and technical assistance units and as
managers of change. Increased decentralisation in management, public participation
and accountability in the management through participatory decision making
structures, like the hospital development committees and the district health societies,
is another major strategy of improving public health system functioning.
e) Flexible Financing: The central strategy of this pillar is the provision of untied funds to
every level - to the village health and sanitation committee, to the sub-centre, to the
PHC, to the CMC and district hospital. Even the strategy of providing a resource
envelope to each district and state, which the district/state has to use against an
approved plan that it develops, is an unprecedented level of financing flexibility.
Financing packages for demand side financing and various forms of risk pooling,
where money follows the patient, are also major strategies declared by the NRHM.
The Janani Suraksha Yojana is one major, almost overwhelming, example of the
demand side financing option, so much so that in many places, the NRHM is being
identified with it. But the challenge of the NRHM is to be able to build more
comprehensive packages that ensure allocative efficiencies within the public health
system and that address equity concerns for the entire range of curative care needs.
Since operationalising these measures involved wide-ranging administrative mechanisms to
be set up, the initial years of 2005-06 and 2006-07 were start-up years, requiring steps to be
devised and put in place at central and state levels.
2007-08 was the first year of full
implementation, and 2008-09 led to its further strengthening.
Continuing and concurrent
review of planning and implementation processes has been considered crucial for such a
mission that involves a large degree of flexibility and constant innovation.
Mandate and Methodology of 2nd Common Review Mission
The mode of a Common Review Mission (CRM) was set up as a part of the Mission Steering
Group’s mandate of review and concurrent evaluation. The last two years - 2007 and 2008-
have been the crucial for the implementation of the NRHM, as many of the plans and
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strategies of the NRHM were rolled out in the states. The first Common Review Mission was
undertaken in November 2007 with the task of assessing progress of the NRHM in thirteen
states relating to the core strategies and the central areas of concern stated in the NRHM
Framework for Implementation. It was able to provide considerable clarity on the main areas
of progress and key constraints that the NRHM was facing.
Now, in the third year since its launch and two complete years of implementation (dated since
the approval of the NRHM framework), the 2nd CRM is an opportunity to undertake detailed
analysis of how successful and how implementable are the strategies of the Mission. It is also
an occasion for collating and documenting the evidence to support or question the
effectiveness of different strategies in different contexts. Thus, the 2nd CRM was undertaken
with the following overall mandate:
1. To review the changes in health system since launch of NRHM through field visits and
spot examination of relevant records.
2. To document evidence for validating the key paradigms of NRHM including
decentralization, infrastructure and HR augmentation, communitisation and others,
3. To identify the key constraints limiting the pace of architectural correction in the health
system envisaged under NRHM
4. To recommend policy and implementation level adaptations which may accelerate
achievement of the goals of NRHM.
Members
Each State team was composed of six members comprising the following:
1.
Two Government Officials (Any two out of the following)
a. Officials of the MoHFW, Gol
b. Officials of state health departments (Health Secretary/ Mission Director/Director of
Health)
c. Regional Directors of Health & Family Welfare
2.
One Public Health Expert (either of the following)
a) Non-official member of Mission Steering Group of NRHM
b) Non-official member of Empowered Programme Committee of NRHM
c) Advisor or Senior Consultant of NHSRC
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3.
One Representative of Development Partners
4.
Two Representative of Civil Society (Any two members from the following)
a) Representative of Civil Society Organisations
b) Representatives of Advisory Group on Community Action
c) Representatives of ASHA Mentoring Group
Each team identified a team leader and a rapporteur. While the team leader was to provide
overall guidance, the rapporteur was to be the point of contact for the team and coordinate
the authoring of the report of the team.
Since each team member had to spend almost 8 days on this mission, it was difficult to
commit the time of so many senior persons for so long. The final list of 67 persons who made
it to the mission team is provided along with the state summary reports.
State Coverage & Timeline
The 2nd CRM was conducted in two phases, one from 25th November to 5th December in 9 of
the 13 states, and the other from 16th to the 21st of December in 4 states.
This was
necessitated by the assembly elections in 4 of the selected states.
The thirteen states covered this year were the following, selected with a view to provide a
representative picture of the progress made: Assam, Bihar, Chhattisgarh, Orissa, Rajasthan,
Tamil Nadu, Karnataka, Kerala,
Madhya Pradesh, and Uttar Pradesh, Jharkhand,
Maharashtra, Mizoram, The first ten of these states were also covered during the 1st CRM.2
On the day first day of the mission, the entire group for phase 1 assembled in the committee
room at Nirman Bhavan.New Delhi, for a briefing chaired by the health secretary Shri Naresh
Dayal (25th November for phase 1 and 15th December for the states covered in phase 2).
After a detailed brief on the terms of reference of the mission, the various divisions in the
ministry briefed the participants on the components of NRHM that they were guiding - sharing
with them the copies of guidelines that the center had provided and the information they had
about the progress of the programme. They also shared some of their concerns and made
suggestions on what the CRM could review during their field visits.
2 The 18* CRM had covered the states of Andhra Pradesh, Assam, Bihar, Chhattisgarh, Orissa, Madhya Pradesh, Gujarat,
Jammu and Kashmir, Rajasthan, Tamil Nadu, Tripura, Uttar Pradesh and West Bengal.
6
On the second day of the mission, there was a one-day briefing by the state officials in the
state headquarters. During this briefing, detailed presentations were made by the state
officials on the strategies adopted and activities undertaken under NRHM in the state.
On the third day of the Mission the team divided into two groups, with each group visiting one
or two districts. The two districts were selected by the CRM team in consultation with the State
mission directorates. The visit to the district lasted two to three days and the appraisal was
done using a broad protocol that indicated the minimum number of each type of facility that
should be visited and the 19 thematic areas that should be covered.
Returning from the districts, the teams engaged in further interactions with the state team and
civil society members. After detailed discussions within the teams, a draft report of the main
issues was made and these reports were presented to a meeting of the key officials of the
state, usually in the presence of the secretary or the mission director. The reports have
subsequently been finalized through email consultations between the team members. The
findings and recommendations of these reports have been consolidated into this one report
and these would be placed before the entire mission team at the national consultation. All
state reports will be available on the NRHM website, as was done for the previous CRM.
The previous CRM had reported on 24 parameters which have this time been combined into
the 19 key aspects of the health service system listed below:
I. Assessment of the case load being handled by the Public System at all levels
II. Preparedness of health facilities for patient care and utilization of services
III. Quality of services provided
IV. Utilisation of diagnostic facilities and their effectiveness
V. Drugs and Supplies
VI. Health Human Resource Planning
VII. Infrastructure
VIII. Empowerment for effective decentralization and flexibility for local action
IX. ASHA
X. Systems of financial management
XI. HMIS and its effectiveness
XII. Community Processes under NRHM
XIII. Assessment of non-governmental partnerships for public health goals
XIV. Systems in place for outreach activities of Sub-centre
XV. Thrust on difficult areas and vulnerable social groups
XVI. The preventive and promotive health aspects with special reference to inter-sectoral
convergence and effect on social determinants of health
7
XVII. Effectiveness of the disease control programmes including vector
control
programmes
XVIII. Performance of Maternal Health, Child Health and Family Planning Activities seen in
terms of availability of quality of services at various levels
XIX. Assessment of programme management structure at district and state level
The progress in the states on these 19 key aspects was to be reviewed against the timelines
set for NRHM as well as the Programme Implementation Plans (PIPs) for 2007-08 and 208-09
of the respective states. The findings on these 19 aspects are being presented in this report,
organized under four broad heads -Service Delivery & Facility Functionality, Human
Resources, Improving Management Systems, and Community Processes. A summary of the
findings on each of the parameters across the states and the key strengths and challenges
before each state are also presented.
8
Findings cf the
Seccnd Ccmmcn Review Missicn
Section -1
FINDINGS OF THE COMMON REVIEW MISSION
National Overview: General patterns
The findings of this CRM have to be understood in the context of processes of institutional
change, and therefore refer to comparisons with observations made during the last CRM
wherever possible.
a. There is a continuing progress in 2008 under NRHM in all the states included in the
review, in terms of improved utilization of services and better functioning of facilities, in
terms of community processes; and in terms of human resources for health and in
terms of flexible financing and improved management.
b. The general trend found by the previous CRM, towards increasing share of services
provided by the public health sector and improving their access and quality, has
continued. Whereas the earlier CRM had expressed doubts about progress in
increased utilization of services- in some states, this CRM observes the pattern of
increasing utilization to have increased across all states. Whereas the earlier CRM
could not be certain that in some states all increased utilization was not merely a direct
JSY effect, this CRM notes that though JSY remains a key driver of increased
utilization, the patterns of increased utilization have now clearly affected general
outpatient attendance and inpatient occupancy and much of diagnostic services as
well and gone well beyond what the JSY contributes to.
c. The variations in roll out across states observed last year persist, though there is some
degree of making up for time lost by the some of the relatively low performers. The
trend of each state rolling out different programme components at different rates
continues, and this could be a problem, particularly in low performing states where
some components have yet to begin- mostly due to state level governance and
management constraints. States that had better baselines and similar programmes in
place had been quick to take off on NRHM strategies, and have now added several
innovations to further strengthen their services. (Integration of NRHM funded health
systems strategy with States with health systems development programmes under
bilateral donors have been insufficiently studied by the Mission, but there appear to be
areas of synergy as well as discordance, and necessary as well as avoidable
overlaps).
9
d. A broad categorization on the basis of achievements in strengthening of service
delivery at all level of facilities3, shows that 3 patterns have emerged: In 6 states all
levels have been strengthened (Kerala, Karnataka, Maharashtra, Rajasthan, Mizoram,
Uttar Pradesh); in 6 states the secondary level facilities (CMC or block PHC) have
been strengthened but PHCs(additional)
remain weak( Orissa, Bihar, Assam,
Chhattisgarh, Madhya Pradesh and Jharkhand). In 1 state, Tamilnadu, the PHCs and
secondary level facilities have been strengthened but the sub-centre services have got
relatively weakened. In the 6 states with additional PHCs, the improvement of sub
centres is varied. It is worth noting that there are state specific contexts and rational
explanations for each of these patterns, which are explained in the next section. But it
also needs emphasizing that there is an epidemiological, and sociological and
experiential basis for insisting on improvements in service delivery at all these levels,
and while partial improvements could be a stage in the process, the commitment to
improvement at all levels needs to be reiterated.
e. The increase in attention to functioning of public health systems along with the infusion
of funds has led to many bottlenecks, almost accepted as inevitable in public systems,
receiving renewed critical attention over the past two years. The Common Review
Mission itself with its sweeping mandate and its broad based composition and its
comprehensive public health systems focus could prove a turning point for the way
health systems are perceived. The fact that the common review mission is a systems
approach linked to horizontal integration at state and district levels has led to
highlighting a much wider level of problems than merely programme specific reviews
would have. The final report is only one part of the CRM’s outcomes. The CRM has
become a systematized process of dialogue between center and state, between public
health experts and civil society and public health administrators, between policy
makers at national and state capitals with programme implementors at the district and
facility level. The final report is able to capture only a part of the richness of this
dialogue as represented in the sum of all central and state level presentations and
district tour reports and state mission reports and submissions on special issues made
by individual members. Even all these documents taken together capture only a part of
the entire dialogue that takes place. Though there are serious concerns about the
NRHM becoming a stand alone vertical programme built around a set of new players,
the major trend is of increasing integration of the new skills with the existing structures
and of attention to cross cutting systemic improvements that impact favourably on all
programmes.
3 Sub-centre and PHC as primary; CHCs, SDH and DH as secondary level.
10
f.
The strengthening of public health management is still in its early stages but even the
modest improvements that have been made can be seen to be paying dividends, with
better flow of funds and better utilization of NRHM funds by the states. Areas of
improvement that are seen across the states are in induction of management, IT and
accounting skills at district and block levels, better financial management largely due to
computerization of accounts, and electronic transfer of funds through e-banking. The
CRM also notes that there are many areas of management improvement where the
NRHM has made path breaking policy advances but their impacts are not yet visible
due to the time it takes to roll out these strategies. At least some of these impacts
should however be visible in time for the next mission. These include creating
management organizations for better procurement and logistics, and for infrastructure
development, institutionalizing concurrent audit, rolling out the new HMIS reform
package, strengthening the SIHFW and putting in place the SHSRCs.
g- There has been an increase in budgetary allocation from the state treasury indicating
an increasing ownership by the states. There has also been a better utilization of funds
in many states- facilitated by the increased in personnel deployed for financial
management. However, absorption of funds remains a challenge. In most states three
factors seem to correlate with poor fund expenditure. One of these is governance
issues which includes stand offs between directorates and state missions, delays or
non attention to building up enough state level management structures especially for
procurement and infrastructure, for technical assistance, and lack of tenure of key
officials. The second is a poor density of facilities and service providers. And a third
would be the highly varied utilization pattern for all the untied funds on flow. Thus
though flexible financing is a great move forward, unless flexibility is further increased
to be able to spend more on facilities and districts with greater turnover of services and
resources, the large patches of untied funds in a few select facilities/districts/states
could slow down the rate of expenditure of the entire programme. Evolving strategies
to deal with this would be a major challenge in the coming year where increased
demand for resources may co exists with poor ability to submit utilization certificates
and unless funds can be channelized from areas of poor absorption to areas of high
demand within districts, between districts and across states without losing sight of
equity considerations.
h. Several core steps for overcoming crucial human resource constraints have been
operationalised, the results of some already becoming evident. The message of the
IPHS norms on human resources is beginning to sink in. The most heartening feature
is that state after state reports substantial additions to the numbers of service
11
providers- especially of nurses and doctors. Not only are we now talking of filling up
contractual slots available under NRHM but also the posts under the non plan
component of state budgets which have been lying unfilled for so long. In some states
it is almost as if an informal freeze on recruitment and indeed on the public health
system which has been put into place in 1992-92 has finally been revoked. The states
of the north are now running out of doctors, nurses and paramedics available for
recruitment in the general pool and further accretions are going to have to wait for the
newly revived nursing training schools and the new medical colleges to turn out new
graduates.
i.
Meanwhile, under the increasing scrutiny for systemic bottlenecks for poor quality of
public service performance, many states notably Bihar, Orissa etc have gone in for
revising the service conditions of their workforce and have begun thinking of career
paths for their staff. Though in most states the depth and range of such workforce
management policies is insufficient
to meet the requirements, overcoming
the
mindsets of the past are not easy, and the fact that the states are seized with these
issues must in itself be seen as a major gain.
J.
The ASHA programme has continued to expand on the ground, and given the
increased space for community participation it provides, the programme is vibrant.
Though there has been considerable progress on removing some of the constraints
noted in the earlier CRM, there is still much that remains to be done. The Janini
Suraksha Yojana has kept her in close linkage with the health system, giving the time
and space for other support systems to be established. As these systems come into
place in the coming year the programme would be strengthened yielding further
measurable outcomes. Other Community processes, especially the village health and
sanitation committee and the community monitoring programme are in variable stages
of take off, but are clearly evident on the ground in all states. NGO participation is
largely in the community monitoring programme where initial reports show that a new
approach is being successfully piloted, and the MNGO programme which is functional
in some states, but as a outcome based national scheme is under review. A few states
are making effective use of NGOs for the ASHA programme and there is scope to
expand this. The rogi kalyan samiti has been successful as a vehicle for untied funds
and for flexible local management, but as a vehicle of community participation in
management, it has yet to get going fully.
k. There are some areas where the challenges have not yet been addressed sufficiently.
One of these is to go beyond RCH prioritized services in the definition of fully
functional health facilities. This could be justified in the low performing states where
12
addressing high maternal and infant mortality rates and high total fertility remains
unfinished on the agenda. However,
even in the high performing states,
the
development of systems for and the integration of non communicable management
into primary and secondary level care remains insufficiently addressed or even
conceptualized into the NRHM framework. Considering that much acute illness and
trauma also needs urgent attention and that social protection of the poor requires
public provisioning of services in these non RCH areas in all states, there is a need to
build comprehensive facility development and
human resource development
approaches to match these goals.
I.
The other major challenge remains of effective decentralization. The Panchayat has a
role in the village health and sanitation committee and some states have provided it
with an effective role in the district health society and the rogi kalyan samiti. A greater
role in governance of health facilities remains elusive and for the most part there Is no
consensus on this across states. The other frontier of decentralization, the district plan
has also advanced further with greater capacity for the same developing in most
states. The challenge is now to make the district plan an effective tool of organising the
health system as a single multifunctional district level network. For this one need to
base district planning on information provided before planning of the resource
envelope available to it, and more pragmatically provide for a post sanction
implementation-planning stage with provision for greater flexibility of moving resources
to respond to needs and utilization patterns within an agreed plan.
13
National Overview: Key Areas of the Health System
The 19 key areas are being presented under 4 heads. Some have been consolidated from the
state reports as such, while others were re-organised, so as to avoid repetition of overlapping
and cross-cutting themes. We have attempted to present the major findings as the teams
have reported them, however consolidation of findings from such extensive reports will always
leave room for some issues getting less attention than a state specific situation warrants.
Towards Achieving Service Guarantees:
Under this head we bring together findings from all the key areas related to the changes in
service delivery and facility functionality and in the utilization and quality of health services.
Issues related to equity and attaining the expected standard of services receive specific focus
here.
Assessment of the case load being handled by the Public System at all levels
There is a general increase in utilization of services after implementation of NRHM, which was
observed last year and has further improved since.
In the high focus states, ie. those with weaker performance earlier, the increase has been
dramatic. For instance, from Assam the team reports that: “NHRM represents a ‘revolution’ in
terms of improving access of the rural poor to health care. According to one community
informant, NRHM has already made a huge difference compared to the pre-launch situation,
which was described as 'the near zero supply of services and immunizations’.’’
Data such as the following has been repeatedly presented from state after state: “Increase in
ORD cases from 7,93,727 in 2005-06 to 8,80,339 in 2006-07 and to 10,05,247 in 2007-08.”
The increase has been at all levels in states such as Rajasthan. In the non-high focus states,
those performing better even earlier, showed that there has been an increase at all levels of
services, as in Maharashtra and Kerala. In Tamil Nadu alone though there has been an
increase in all levels, the shift in utilization has been more markedly to the PHCs as compared
to other levels and sub-centres and ANMs (called the VHNs in that state) have lost out in
terms of their role in service delivery.
However it has been relatively greater at secondary levels such as CHCs, Sub-district and
District Hospitals and at the cost of the primary levels in states such as Orissa, Bihar and
Chhattisgarh. “It is well evident from the community interaction that ORD services and normal
delivery is an increasing trend in many CHCs and SCs. However this trend is not seen in PHC
facilities. ORD services and institutional delivery in many PHCs has gone down....”
The analysis about reasons for increase in utilization has been varied across the teams:
14
■
“due to better availability of services, better infrastructure and 24x7 availability of
services.”
■
“main reasons for this are in the improved human resources deployed."
■
“The institutions where doctors are coming regularly particularly in CHCs the
increase in indoor patient load is quite encouraging."
■
“the decentralisation, responsiveness to local needs, paradigm shift in health
system management and availability of untied funds has improved the facilities and
their credibility among members of the public. JSY, community mobilization by
ASHA, and proper referral transport have contributed to a large extent in increasing
the case load. However greater patient load has been noted in the district and subdivisional hospitals and CHCs as compared to PHCs and Sub-centres. It was
observed that there was a total dependence on the government health system in
the absence of a significant private sector."
■
“Definite improvement seen in the outpatient load of Sub-centres, PHCs and Rural
Hospitals (CHCs). 24X7 Block PHCs are offering outpatient, emergency and
institutional services. Sub-centres are regularly doing deliveries. (A separate labour
room built from the State budget has increased the numbers) Basic reason for
increase in inpatient load at PHCs and CHCs is increase in institutional deliveries
partly due to JSY and also because of upgradation of the quality of the
infrastructure, clean toilets, water availability, inverter for alternate source of
electricity, free meals and also due to feel good factor generated by the
beautification of the Centres and Hospitals and their surroundings.”
The lack of increase at certain levels and in some facilities was attributable to the policies
adopted in the state.In Bihar the understanding was- since in every place there is a situation
of near collapse, it would make sense to start by prioritizing improvements in the main block
PHC (CHC), i.e. of secondary level strengthening as priority over the primary level facilities.
By concentrating available resources in these areas the quick improvement was observed.
But now, as CHCs reel under the pressure, there is a rethinking going on on how to revitalize
the sector level PHCs. This is the same situation in Orissa and Jharkhand and Orissa too,
though Jharkhand is not yet seized of the issue. In Chhattisgarh the lack of nurse additions at
the PHC level may be the main constraint- in a context where most PHCs are anyway being
managed by non-MBBS providers.
The JSY's impact on services at different levels varies. It has, for example led to decrease in
services by ANMs in terms of conducting deliveries in several states, and where the PHCs
were not geared up, this has led to overcrowding in the CHCs and District Hospitals.
15
In other states where SC strengthening has received attention, the OPD care and deliveries
have increased even at SC level.
For example Maharashtra reports that “Definite
improvement seen in the outpatient load of Sub-centres, PHCs and Rural Hospitals (CHCs).
24X7 Block PHCs are offering outpatient, emergency and institutional services. Sub-centres
are regularly doing deliveries. (A separate labour room built from the State budget has
increased the numbers) Basic reason for increase in inpatient load at PHCs and CHCs is
increase in institutional deliveries partly due to JSY and also because of upgradation of the
quality of the infrastructure, clean toilets, water availability, inverter for alternate source of
electricity, free meals and also due to feel good factor generated by the beautification of the
Centres and Hospitals and their surroundings.”
In several cases, the facility is under-utilised due to irrational positioning of too many facilities
too close to each other. “In-patient load at the Sub-district Hospitals is below optimum due to
not so comparatively efficient facilities available (as told demand for services was not there
due to presence of a 24X7 PHC nearby. It was informed that the State had been proposing to
shift the Sub-district Hospital Bhor to an area where it was required in the same district).” The
use of the district planning for rationalizing the use of resources- infrastructural and human
resource- within the districts would help in achieving this objective.
Preparedness of health facilities for patient care and utilization of services
The facilities at all levels are getting strengthened in several ways. However one important
observation is that given human resource constraints, improvement of service delivery at
facilities that are considered to be of greater priority are often at the cost of services at the
other facility levels- since the same limited human resource is shifted around.
District hospitals: In most states these have been the strongest in terms of infrastructure and
posting of doctors including specialists; being situated at the district headquarter town, where
the health personnel tend to cluster, and catering to the local middle-class. In several states,
their infrastructure has been strengthened by health systems development projects of the
World Bank from the 1990s. However there is a huge variation in terms of their quality.
Several states are now in the process of obtaining Quality standards certification for their
district hospitals from either the NABH or the ISO, in the ‘high focus’ states as well.
District hospital at Bahraich is clean and well maintained. The ambience of the campus is
good including plenty of greenery and also comprises of a committed team. There has been
improvement in health facilities during the last one year. The hospital is in process of
accreditation by NABH. Bed occupancy rate is more than 100%.”
16
“District Hospital Serchhip has got a new trauma wing and blood bank building, but the DC of
Serchhip made a strong case for undertaking renovation of the main hospital building. Civil
Hospital Aizawl and Champhai District Hospital upgradation project initial stage has begun.”
On the other hand, in some districts the district hospitals have barely reached the level of
services of a PHC or CHC. In other places, there are district hospitals which function
minimally despite a large infrastructure, due to shortage of personnel, or mismanagement and
poor performance of the personnel posted there.
“In obstetric care the quality is seriously hampered by a lack of nurses and midwives- the
ratios being extremely adverse-13 nurses only to staff 60 beds with over 100% occupancy, to
staff the heavy outpatient, and the obstetric room where only two nurses become available
with 210 beds there are still only 19 nurses and midwives taken together and only two nurses
in a labour room that could have upto 50 deliveries per day.”
Community Health Centers: The CHCs, being later entrants in the chain of facilities starting
in the 1980s, were developed by upgradation of PHCs as well as by creating new facilities and
this process is still continuing. Since the upgradation processes have been undertaken at
different points of time and to varying degrees, the nomenclature has tended to get muddled.
Block PHC, Upgraded PHC or just PHC, Referral hospital, Rural hospital: these are terms that
have been used to denote a facility that is being developed on the lines of what has been
conceptualised as the first point for provision of specialist medical care, overlapping between
primary and secondary level services. In some states the facility labeled PHC is on its way to
strengthening infrastructure and human resources towards this. In others, the CHC is well
established as a provider of secondary services. In all situations, there is a shortage of
personnel, especially the specialists who are not joining the public services, and staff nurses
who are not being produced in adequate numbers and few have reached the IPHS.
“Some CHCs have less than 30 beds. However, owing to increased load due to the JSY,
additional wards are being constructed...”
“CMC lacking in specialist manpower, non-functional OT - referrals to District Hospital”
“Uttar Pradesh has two types of PHCs. The PHCs situated at block are called block PHCs
which currently are catering to about 1 20 000 to 1 50 000 population. In the districts we
visited, these PHCs are run by MO l/C and an AYUSH LMO. The third MO is not posted.
These PHCs function as 24x7 facilities. Mostly deliveries are conducted by Staff Nurse and
ANMs of the attached SC. The laboratory facility is grossly underutilized as only basic clinical
investigations are carried out. Eventually all block PHCs will be converted into CHCs.
Construction work is in progress. ”
17
The First Referral Unit (FRU), a terminology originating from the RCH-I programme, requires a
certain set of services linked to maternal health services with commensurate equipment to be
available at a facility—the minimum being a set of 3: conducting caesarian section, blood
storage/banking, and a neonatal care unit. The CHC, sub-divisional and district hospitals are
the ones that are in a position to provide these. Since the CHC is also defined under IPHS to
have all these features one could see this as a parallel terminology to the CHC. Since these
three definitions of the FRU are anyway the most challenging aspects of raising the CHC to
IPHS standards there are few if any CHCs which could become FRUs without also
simultaneously achieving or being in a position to achieve IPHS standards. However, the
review shows that in several cases, designating facilities as FRUs by the state is more a
‘statement of intent’ rather than actually having ensured ail the 3 minimum criteria being met.
What was evident was the effort to move towards fulfilling them, but the road map was not
always clear or even thought out. Even the licensing of blood bank/storage had also been
done on the intent rather than actual equipment and human resources (for blood storage, of a
medical officer and a laboratory technician with training in blood banking) availability at the
facility.
Primary Health Centres: This facility which is meant to provide the first interface with a
doctor, provide comprehensive promotive, preventive and curative services, and provide
supervisory support to personnel at further peripheral levels- the sub-centre, the village
health workers (now the ASHA) and the anganwadi centres - is receiving priority attention in
some states such as Tamil Nadu and Rajasthan.
In others it tends to suffer because of priority to the CMC level and the DH. Doctors and
ANMs are shifted or attached from the PHCs to the CHCs and DHs in order to operationalise
the curative services at the secondary level, taking the basic medical care further away from
the villages, and to the neglect of preventive primary care. The concept of pooling from where
this practice originated also implied running the PHC with paramedical staff and providing for
the medical officer to visit daily or thrice a week during office hours. But often, especially In
Jharkhand the withdrawal of staff from the PHC to the CHC was not linked to these two
measures leading to a net reduction of peripheral services. Now as the CHC level services
picks up the attention shifts back to restarting up the PHC. The supervisory role meant to be
performed by the PHC personnel for the sub-centres and village level work as well as disease
control programmes has also suffered due to the shortages of personnel at this level.
The great variation in preparedness of PHCs across states and within states is also depicted
in the terminology that has come into use for this level of facilities: Additional PHC, PHC
(new), mini-PHC, PHC etc. These need to be differentiated from block PHC, main PHC or just
PHC denoting potential or putative CHCs. These two sets differ in terms of the population
18
coverage norm to be followed, the number of doctors, staff nurses and ANMs sanctioned, the
number of beds, as well as the supervisory duties expected from it. They also represent the
process of incremental development of the facilities.
What are called PHCs in Tamil Nadu are functioning at the level of CHCs in other states
In Uttar Pradesh ‘24x7 PHCs’ represent the conversion of facilities that were barely functional
in the day for a few hours, thereby limiting the range of services they could provide and the
level of trust they could invoke in the community, to facilities providing round the clock
services. For this they have had to ensure availability of at least an ANM or Staff Nurse at all
times along with a doctor at least on call, thereby not only conducting deliveries at night but
also increasing the range of other emergency services and other indoor care they can provide.
PHCs in Bihar have been revived and are to be upgraded to CHCs while the Additional PHCs
are to play the role of PHCs. The PHC (New) in Orissa are upto a decade old and are now
revived with posting of Medical Officers and/or AYUSH doctors on a contractual basis under
the NRHM.
In several cases, the placing of facilities too close to each other has meant that the inputs for
strengthening are wasted since utilization remains low.
In a number of states, there Is an effort to outsource management of the (additional) PHCs to
make them functional. Bihar leads in this. The first round effort did not succeed and now there
is a second round effort ongoing. This has also been tried, but in a limited way in Orissa and
in Uttar Pradesh and Rajasthan. In the latter states, the outsourcing is done only where there
is a NGO which offers special advantages- a niche strategy - but not as such meant for
general replication. “The SDH, Sagwara is functioning very well and attracting increasing
case-load. It is a unique model of PPP (through charity and managerial participation) but may
be difficult to be replicated. However, this has also meant meagre case-loads at adjoining
PHCs. An analysis of ‘C to E’ forms reveal that many minor case are being treated at Sagwara
and the DH, Dungarpur which can be adequately treated at CHCs and PHCs. Minor wounds
constitute a large load at these institutions, much of which can be tackled at SCs, PHCs and
CHCs.”
Sub-Centers: The sub-centres have received a face-lift in all states, and are providing RCH
services through an ANM, the MPW (M) being a missing cadre In the facilities visited. Second
ANMs have been recruited in several states, often without fulfilling the NRHM requirement of
filling the MPW (M) post first, and with no specification of role or division of work between the
two ANMs.
19
“It has been observed that most of the SC are giving better services than in the past because
of the availability of untied fund and their proper utilization, In most of the SCs visited basic
materials including paediatric ambu bag, delivery trey, table with mackintosh sheet, Boiler, AD
syringes, needle cutter etc. are noticed as functional. General cleanliness in SCs are good
except where it is functioning from a rented building. Problems for water supply, electricity bill
payment are reported from SC. Another good initiative is availability of functioning telephone
connection at SCs. It has been reported by the community during group discussion that the
team work between ANM, Mitanin and AWW are exceptionally encouraging.”
“Sub-centre buildings, even those in rented spaces, were observed to be satisfactory. They
were equipped with labour table and other basics, but were hardly in use, either due to non
residence of the ANM, or because of referral to CHCs/hospitals under JSY. MPW (M) were
not posted in any of the sub-centres visited, affecting the provision of basic curative care and
the disease control programmes.”
However, in some states the maternal health services of the ANM have been weakened by
the JSY and the shift of site of deliveries to the higher level facilities.
Quality of services provided
Quality of services can be assessed against objective indicators of the efforts at strengthening
of facilities and services, as well as the indicators of impact on health of the population. Or it
can be viewed in terms of satisfaction of the users, and the provider’s assessment of their
work and working conditions. The CRM was not designed to assess impact on health status,
and it may be too early in the roll out of the NRHM to expect such impact, but it was able to
examine the changes/improvements in parameters that contribute to quality. It also reflected
on perceptions of the users and providers of services.
Patient satisfaction: Patient satisfaction was in almost all places very positive.
In some
settings, the recent memory of a complete lack of services and the current changed situation
was upper most in people’s minds. In other settings where services had been available and in
use even earlier, there was an appreciation of the improvement in quality of the physical
surroundings, the availability of doctors, of drugs and of a more woman friendly environment.
Provider satisfaction: Provider satisfaction was more qualified, but even then on the whole
very positive. There was a strong and positive sense of change, of things having been
achieved, of their being able to deliver more services. There was much dissatisfaction with
service conditions and payments at all levels and with different issues related to support
services. One recurrent expression was “the work load has improved so much but there Is
little improvement in staff or facilities to manage this increased workload."
20
However, where “no substantial improvement in physical infrastructure was seen, the doctors
and nurses also commented about the requirement of better infrastructure. The local
community including patients on the other hand gave a mixed response. While they noted the
improved infrastructure, the quality and range of services was still felt to be inadequate.”
The CRM teams in almost all states observed some improvement in the levels of cleanliness,
provision of waiting space for patients, etc. but cleanliness of toilets was still wanting. Also
noted was the need for attention to procedures for registration, patient flow and information
through appropriate signages, to waste disposal and other aspects crucial for a patient friendly
facility. The shortage of human resources and thereby of the expected services was also
noted as an issue of quality. Of course, wide differences were evident through the reports in
terms of quality of infrastructure and functional processes of the facilities, as reflected in these
quotes:
“All facilities were well maintained with proper cleanliness, disposal pits constructed (using
RKS funds) - paramedical and group D staff trained in IMER at District Hospital.”
“Overall some improvements have been made in the services like cleanliness, waste
collection, electrification and water supply, but are inadequate. While there were extra
sweepers appointed from untied funds and maintenance grants, there is still scope for
improvement in the cleanliness of toilets and availability of water supply in some hospitals.
Many hospitals have colour coded bins supplied but the practice of segregation of hospital
waste at source is not practiced by all the staff.”
“the infrastructure is old and requires repairs. New building is under construction. OPD patient
load is very high, institutional delivery load is also very high.
Drug supply is adequate.
However the PHC has only 4 beds which require to be augmented, and there is no referral
transport service
available.
Laboratory services
are
inadequate.
Bio-medical
waste
management facility is available.”
“There are many facilities below the district level which are not as per the recommended
norms and nomenclature viz. State Dispensaries, Subsidiary Health Centres and Mini-PHC.
Block PHC is the administrative unit for health activities of the block. Availability of specialists
was not as per norms. At one CHC, Surgeon, Physician, Pediatrician and Radiologist were not
available while 2 Gynecology & Obstetric specialists, 2 Anesthetists and 1 Dental Surgeon
were available. At another CHC, Dental surgeon was available but dental chair was not
available. Here, there were no facilities for sterilizations and MTP. At a District Hospital, eye
surgeon was available but not doing eye surgeries due to lack of facilities.”
The efforts for improving services have been made through regular staff, contractual staff as
well as through contracting out of services. The arrangements differ widely across states,
21
especially in terms of the terms and conditions of the private providers of the outsourced
services. “There is a systematic effort to provide generator support, pathology diagnostics, Xray and soon ultrasound as well, ambulance services, laundry services, diet services and
cleaning and sanitation services, and monitoring services by outsourcing each of these
services. This has kick-started all these services, and today these services are available either
from the outsourced person or from the facility’s own resources in the majority of facilities
visited.
The fear expressed by one of the teams seems to echo the general finding in the high focus
states that, “given the problems of the past, expectations of providers and even of the public
had been set at very modest levels. The system is in danger of stabilising at this low level of
expectations and outputs, and even as one appreciates the effort that has gone in to reach
this level, there is a need to set the benchmarks higher. There is much more that needs to be
done, if the increased patient load and utilization of services was to manifest in increased
outcomes.”
Utilisation of diagnostic services and their effectiveness
Significant improvement in diagnostic services was observed, even in the high focus states.
While this was across all levels of facilities, the degree to which diagnostic technologies had
been made available at the primary level varied widely across the states. Those with well
endowed PHCs presented a picture unimaginable in others:
In Maharashtra, “All 24X7 PHCs are provided with lab providing basic facilities; semi-auto
analyzer and special services like ECG, X-ray in these PHCs; DHs have ECG, X-ray,
Ultrasound with CT-Scan. These services are available at reasonable user cost. Use of
pregnancy diagnostic kit for early diagnosis of pregnancy, hemoglobin, urine for albumin and
sugar test to rule out anaemia, diabetes and pregnancy induced hypertension." In Tamil Nadu,
the diagnostics are at a level that it seems to require an examination of the extent of their
rational utilisation in all facilities, “The Block PHCs are provided with Scan and all the 235
upgraded PHCs are provided with ultra-sonogram, X-ray, ECG and Semi auto analyser."
In the high focus states, despite the shortages of Laboratory Technicians in some states, they
have worked out mechanisms for ensuring services: “There was an effective pooling of lab
technicians from malaria, TB, HIV/AIDS for efficient handling of investigations and diagnostic
workload in the DH/SDH/ CHC level. Blood banks at the DH are functional with a lab
technician. However basic infrastructure is often found lacking, such as water supply and
registers for lab technician are not in place. ...Lab facilities are not available at PHC (N). X ray
facility is not available at Sub divisional hospitals and CHC levels.”
22
“The state has made sincere effort to improve access to quality diagnostic services through
public private partnerships. Outsourcing models have been developed to contract-in private
providers for offering clinical laboratory as well as X-ray services from the premises of public
hospitals and PHCs. While these innovations are noteworthy and are in the right direction,
some operational constraints were noted during the field visits.” The shortcomings included
the private providers’ reluctance to set up laboratories in PHCs, the overlap of both public and
private in some settings, and the lack of basic quality protocols as well as bio-medical waste
management practices in both public and private laboratories visited.
User charges are still being taken for diagnostics in most states, though generally below the
market rates. BPL are exempt from the charges.
Drugs and Supplies
All states report significantly better availability of drugs and other consumables from the
situation in the past. The availability of drugs was also displayed on the wall of DH/CHCs/
PHCs as a measure to improve confidence of the public. But medicines and other
consumables are still found to be inadequate in many facilities since the increase in supplies
has not been commensurate with the increase in patient load. Also logistics systems are slow
to develop and there are frequent stock out of high volume drugs in a situation where patient
attendance and therefore drug utilization is constantly rising. In the high focus states, putting
in place a district warehouse for drugs with a trained storekeeper and a demand responsive
system of drug distribution remains a priority.
“Inadequate budget for the drugs (Rs.1 Lakh for CHCs, 0.5 lakhs for Block PHC & 16000 for
PHC (N) have put ‘out of pocket' burden on patients including for emergency surgery and
treatment.” “Despite steep increase in state expenditure on pharmaceuticals during the past
few years, the per capita public expenditure on pharmaceuticals (around Rs. 8 per capita) is
too low compared to the about Rs 49 per capita (USD 1) recommended by WHO.”
In states where the system strengthening is still in take off stage, like in Jharkhand the existing
picture presents the contrast: “There is shortage of drugs and other supplies at most of the
health facilities including district hospital. At all places patients have to purchase 1/V drip sets
and sutures. Inj. Magnesium sulfate and MVA kits were not available at PHC/CHC/FRU.
Ayurvedic drugs are not provided for use by Ayurvedic Physicians and these doctors were
found to be prescribing allopathic drugs only. Supplies of Dental consumables are poor. At
one place Dental X-ray Unit was available but X-ray films were not available.”
Generic Drugs were found to be “available in institutions (PHC/CHC/DH) through Cooperative
Store and LLPS - 30-50% cheaper than MRP.” In many states, the Rogi kalyan samitis are
providing free medicines for the BPL families. But access to essential drugs mainly requires
23
increasing the list of essential drugs supplied in the facility and making outside prescription
unnecessary.
AYUSH Services for Facility Functionality
Almost all the CRM States have started with collocation of AYUSH practitioners in PHCs,
CHCs and DHs except in Bihar (where the AYUSH infrastructure is still weak in the public
sector) and Kerala (where the state has more AYUSH facilities than modem medicine). Some
states have reached high levels of co-location like Maharashtra and Rajasthan whereas
others have done so very partially such as Assam and Jharkhand.
However, at least in Orissa, Maharashtra, UP and MP, the CRM teams have observed that
the AYUSH doctors are working as an arrangement for ‘substitution’ of the allopathic doctors
rather than as ‘co-location. In Orissa, the Mobile health units are also being managed by
AYUSH doctors. Almost all the states with co-location reported that the AYUSH drug supply is
inadequate and none of the report mentions the presence of AYUSH paramedics.
Systems in place for outreach activities of Sub-centre
The regular schedule of household visits by an MPW, male or female, is not in place for a
number of years. Partly this seems to be due to the missing MPW that was in withdrawal since
the nineties and partly this has been attributed to the high coverage population that many sub
centers have to attend to and partly it is due to the Pulse Polio drives which is reported to take
up as much as a 100 days of their time in some states. The emphasis under the NRHM, is
therefore on an increase in outreach activities through the ASHA who is the main plank for
home visits and through the Village Health & Nutrition Days organized at the ICDS anganwadi
centres where the family comes to the outreach center to be met by the ANM on a fixed day
every month. Both these strategies are working reasonably effectively, though in many states
the VHND is primarily an immunization session and ANC clinic where ASHA, AWW and ANM
come together.
“Fixed VHNDs at the Anganwadis are increasing ANC registrations, immunization, growth
monitoring & nutrition counseling activities. 6 Mobile health units are in place managed by
AYUSH doctors.”
In Tamil Nadu, there is a different trend with the sub-centre beginning to lose out in service
delivery, and the ANM becoming more a mobiliser than a care provider, “The lone VHN (ANM)
at the SHC is pre-occupied with mobilisation of women for ANC, PNC, Immunisation
programmes at PHCs and transportation of pregnant women to the PHC for delivery. The
ANMs are further engaged in the school health and adolescent health programmes and thus
leaving hardly any time for domiciliary visits and other outreach programmes of SHCs. The
24
fl
outreach programme VHNDs at Anganwadi Centres is not visible in any of the districts
visited.” However the understanding is that the health seeking behavior of the public is now
requiring that a doctor needs be available for even immunization to happen- and reportedly
this is the situation in Kerala also. This may be the reason why the state of Kerala has
preferred the ASHA who is a mobiliser to a second ANM. This needs to be explored further
and the implications for this for high performing states which are still far short of 100%
immunization and seeing reversals in this needs to be understood.
Thrust on difficult areas and vulnerable social groups
States have identified the ‘difficult areas’ as either the ones that are ‘hard to reach’ because of
the terrain and poor communication infrastructure or the ones with a high proportion of
population from the ‘vulnerable groups'. The identified vulnerable groups are the tribal
populations, Scheduled castes and families Below Poverty Line. Mobile medical units,
creating higher density of facilities for better coverage, and giving the personnel ‘difficult area
allowance’ are some of the measures to ensure services in these difficult areas and to
vulnerable groups. Some of these initiatives have been taken under the NRM and some were
already part of the regular services and have received additional support from the NRHM.
“Tribal Area Sub-Plan (under the treasury, outside the NRHM) has substantial effect in the
tribal areas with additional funds for construction of Sub Centres and also additional salary
support for the 2nd ANM. Most of the Sub Centres in Dungarpur (TSP district) has two ANMs.”
“The KBK districts are clearly identified as underserved districts and special provisions have
been made to strengthen services, such as special incentives for health staff serving in KBK
plus districts. A few ‘hard to reach’ areas in other districts too are managed by NGOs under
PPP. However, all districts need to map the most vulnerable pockets and ensure convergent
services for them.”
In the non-high focus states, several NRHM schemes were not applicable for the whole
population but operationalised only in the difficult areas. For instance, in Maharashtra, “the
ASHAs in the beginning were only for tribal areas, multi speciality training on priority of nurses
and doctors posted in tribal and extremism affected areas, separate batch of girls for nursing
schools from tribal areas with higher stipend (twice of the regular), Rs. 1000/- pm higher
payment to nurses in tribal areas and Rs. 1500/- pm higher payment (both contractual and
regular) working in extremism affected Nagpur Division. Exact per month payment of ANMs is
ANM in rural area sub-centre- Rs. 7000/- pm, ANM in naxal area sub-centre- Rs. 7500/-pm
and ANM in unreachable Sub-centre - Rs. 10,000/- pm.”
Effectiveness of the disease control programmes including vector control programmes
25
9
Operationalisation of the disease control programmes has been strengthened by the
improvement in the service system as a whole. The various programmes are also interacting
and supplementing each other in some aspects, such as use of Lab. technicians across
programmes. The shortage of personnel at various levels is leading to other innovations as
well, for instance for Anti-Malaria activities in Orissa, “ Time taken for reporting of positive
cases of malaria by the laboratory is three weeks to one month, with gross shortage of
Laboratory Technicians. LTs were also allocated to the State by Gol from the Malaria budget.
There are problems in finding candidates who are trained in malaria (MLT), so the state has
decided to engage the candidates and train them in Malaria Microscopy and rename the post.
The state may consider opening institutions for the training of LTs to meet the emerging
demand of LTs at the sector level PHCs
The posts of MPW (M) are vacant and contractual
appointment is underway, which is expected to result in improvement in surveillance and
delivery of treatment to the patients. ASHAs, who have received additional training as per the
state’s needs, are facilitating detection of Malaria/TB/Leprosy cases. They make blood slides
for malaria and give them to the ANM. For TB and Leprosy, they are familiar with the
symptoms and signs and counsel the suspected cases to go for medical help.” Similar human
resource problems are being faced even in states such as Tamil Nadu, “There are no
shortages of laboratory chemicals at the microscopy centres as well as sub-district hospitals.
The case detection rate and availability of Laboratory Technicians are of concern in tribal and
underserved areas. There is acute shortage of male Health Workers and the services of
available 400 NMS can be utilised for implementation of DCPs.
In most of the upgraded
PHCs, alternate arrangements are made for taking x-rays, ECGs and other routine
investigations. The ICTC technicians are also providing additional support.”
The Revised National Tuberculosis Control Program is doing well in all the states, with
adequate detection and cure rates. It was thought that some attention is required now for
improving detection rates, especially focussing on unreached groups and spatial pockets,
“The RNTCP is reported to be doing well as per programme parameters. However, the fact
that this is a mountainous area with many areas unreached is an indicator that the state needs
to be looking actively for uncovered groups and areas, and not go by nationally-determined
indicators of performance.”
State specific problems are being dealt with as priority, for instance Kala-azar in Bihar, sickle
cell anemia in Maharashtra and non-communicable diseases in Kerala. “The supply of anti KA
drugs has improved in Bihar where Kala-azar contributes to 80% of nation’s disease burden.
Inconsistency in treatment protocols and non familiarity of treating doctors with the current
program treatment guidelines are major concerns in this program.”
26
The IDSP is working in some states, with start up of data entry and collation on-line from the
field and laboratories. Use of the data to track disease patterns and outbreaks is yet to begin
in any appreciable way. “The State and district level IDSP is being strengthened, with
appointment of data entry operators, data managers and district surveillance officers in place.
However, the Rapid Response Team needs to be further strengthened for outbreak
investigation & further action. The P, S and L forms are being routinely submitted. However,
issues with data validation and feedback for prompt action still remain to be addressed at
various levels. The State and District labs still need further strengthening.”
Performance of Maternal Health, Child Health and Family Planning Activities seen in
terms of availability of quality of services at various levels
Maternal and child health services have moved at a varying pace over the period of the
NRHM. In all states, there has been a continuing increase in number of deliveries conducted
in institutions. Institutional deliveries have increased in the 13 states included in this CRM.
This is evidenced in all visits made and confirmed by the changes in the DLHS data for these
states. Institutional strengthening for this has also happened to varying degrees.
However, the same degree of attention has not gone to child health initiatives. The unmet
need for contraception also raises issues about performance of basic services by facilities.
Maternal Health:
Preparedness for Institutional Deliveries: The facilities providing the services for increased
institutional deliveries vary across the states, as already discussed. Where the primary level
facilities are not geared up, the deliveries are all reaching the secondary level facilities—the
CHCs (or their equivalents which are being termed PHCs in some states), SDH and DH—
which face severe over-crowding, shortage of beds and therefore inability to keep the mothers
for 48 hours post-partum. They are also not able to provide the services for mother and child
that are possible if full use is made of the opportunity provided by a mother and new born
being with the health system.
Ante-natal care has been strengthened by the early identification of pregnant women by the
AWW and ASHA. However, the quality of ANC remains a challenge. The Orissa team
observes “the ANMs at Sub-centres are now working mainly as ‘ASHA managers’ and data
providers for the HMIS, at best providing some ANC and contraceptive services. Even the
quality of ANC services is severely limited by the fact that in most cases, neither weight gain,
BP nor Haemoglobin are being monitored. Only prophylactic dose of IFA is being given with
no one receiving the therapeutic dosage. Institutional deliveries are happening at the CHCs
and above since the PHCs do not have MBBS doctors or Staff nurses. The most vulnerable
ST families still depend upon home deliveries which the ANMs are NOT conducting. This is
27
evident in the data provided at district level, and at the sub-centres visited. Dai training has
been discontinued but the home deliveries are being conducted by the dais (TBAs). In this
way, a ‘de-skilling’ of ANMs and no support for dais is likely to weaken the service delivery
system at the peripheral level, especially for the more vulnerable sections who are unable to
travel to institutions at a distance, despite JSY support. Mechanisms for linking of TBAs with
ANMs needs to be evolved for reaching skills of ANMs in yet the underserved areas /
population groups.”
In states where all round facility strengthening has happened, the ANMs are performing
deliveries at sub-centres, homes and PHCs. ANC is limited by attention to it as an activity in
some of these states, but as in Tamil Nadu and Maharashtra, ANC is utilised as an
opportunity to build rapport with the mothers and their families, introduce them to the delivery
facilities in the public sector, and provide ail the requisite care.
The deliveries conducted in SCs are considered institutional deliveries only if they have
facilitate as per IPHS. The PHCs upgraded with 3-4 ANMs/SN for provision of 24x7 maternity
services often lack the medical backup and so, “in order to meet the short fall of doctors at
these PHCs, particularly Lady Medical Officer (LMO), the mission has decided to recruit 428
lady doctors from Indian System of Medicine in order to post them at the 24x7 facility and
given them adequate training in EmOC.”
In settings where the ANC contact with the health system had been satisfactory and the
facilities have been made woman friendly, it was reported by the CRM team that,
“During the
interviews with the recently delivered women in the health centers and hospitals, it was
evident that they prefer to stay for 2 to 3 days in the health facility for normal deliveries".
Post-natal care has been a relatively neglected area, with mothers going home within a few
hours after delivery, as reported from most states. This is the period when both mother and
neonate are at high risk of morbidity and when a large part of the infant and maternal mortality
occurs. “The mission found that the operationalisation of block level PHCs and the increased
focus on additional PHCs was providing a platform from which access to maternal health,
child health and family planning services had been expanded.”
The payments for JSY are being made in time in some states, but mothers face much delay in
others. Referral/emergency transport for pregnant women was observed to have been
operationalised in most states, thereby actively facilitating the women’s access to institutions
for delivery.
In some states, it was observed that the private institutions empanelled for
deliveries under JSY, do not provide adequate care for the new born or keep records of the
child’s health.
28
)
There has, reportedly, been increase in incomplete abortion coming to institutions, attributed
by the MOs to Misoprostol misuse by unqualified practitioners. This is an observation that is a
cause of concern, since both the woman’s morbidity and maternal mortality may increase, and
must be examined. The expansion of safe abortion services is also slow.
Child Health
The teams found that the monthly Village Health & Nutrition Day (VHND) was being
conducted in most states at the AWC with involvement of the ASHA, ANM and the VHSC,
operationalising the AWC as a major site for child health related activities before school-going
age and the school health programmes can impact on the age group. These points provide for
inter-sectoral convergence on child malnutrition, illness or disability detection and
immunization. It also provides opportunities for interaction with mothers. However, in some
states the VHND strategy has not yet taken off, and in some others it serves only to
implement the immunsation programme. “The immunization programme had reached through
to sub-centre/AWC level and appeared to be operating well. Fixed weekly immunization days
have been are being held in AWCs and sub-centres...
However, other child health
interventions are not consistently emphasised, and supplies (including ORS) were not
uniformly available in all centres visited." Even the new born corner was not found in most
facilities conducting deliveries.
The focus on, and skill development for, dealing with childhood illness is envisaged through
the IMNCI, but the planned training is largely to the ANM and too slow to make significant
impact. Nutrition Rehabilitation Centres are being set up in some states for the grade III and
IV malnourished children—“The NRCs in the District Hospitals visited were excellently run and
maintained. This is a very encouraging endeavour to tackle the issue of malnutrition In the
area”. However, the numbers do not match the level of need as per NFHS data on
malnourished children, so as observed by one team, “The State has initiated the setting up of
)
Nutrition Rehabilitation Centers in 2 districts, but a more comprehensive approach is needed,
integrating preventive, promotive and curative nutrition interventions." The rolling out of facility
based care at the PHC and CHC level is also too slow and too varied across the states. There
is need for a composite planning linking the IMNCI training for home and facility based care,
SCNU, ICDS and NRC as well as the maternal services.
A systems approach to maternal and child health could try to take together all the strategies at
the sub-center together into one single training package and at the PHC into another single
package and at the CHC and district hospital into a third single package and then build
training and support strategies based on this rather than introduce so many different packages
at so many different rates across the state. However child health has benefitted from the large
29
increase of ASHAs and nurses in the system as almost all of them are geared to provide
some services to the sick child.
Family Planning
The assessment of progress in family planning services was mixed.
One heartening development was that achievements in NSV are impressive against targets
and coverage with this is rising. This needs to be sustained with more mobilization efforts as
in absolute terms NSV is only still a small part of overall sterilizations. Male participation in
family planning needs to be promoted further, and the MPW (M) may be a vital cadre for this.
Tubectomy figures in some states seem to be declining. Even where it is happening the
increase is nowhere near the type of increase being seen for JSY. Much of the problem could
be on the supply side as fixed day per week sterilization is not yet achieved in many centers.
However in contrast to the last visit more facilities have reported this to be happening.
The ANM seems to remain the mainstay of the contraceptive services for spacing methods.
“All centres have a list of eligible couples. There is a) very high uptake of the oral pill as
evidenced from the NFHS-3 (10% of ECs) and the DLHS-3 (12%).”
“Large numbers of
women are on the oral pill records of health workers, but the quality of service is wanting.
Counseling is cursory, and an extra pill packet is not given (to prevent stock-out at the level of
the user); drop-outs are not methodically contacted. Going by the records, it is possible that
several women run out of pill supplies.” “IUD insertions are being done by all ANMs, while
there is an increasing use of oral pills without any monitoring of side-effects.”
Infrastructure
There has been a face-lift of a large number of facilities in all states, with extensions, repairs
and maintenance works. This was observed in the high focus and non-high focus states. For
example the mission to UP observes, mostly clean, green and well maintained district
hospitals and CHCs and committed team, committed District Magistrate, excellent
improvement during the last one year. Very spacious HSC buildings, generators and inverters
are available and in Tamil Nadu, all the PNC premises have a new look as most of the civil
works were completed including provision of toilets, water supply and uninterrupted electricity
including generators. The PHCs are well equipped with ILR, Deep Freezers, Sterilisers,
Autoclaves, Semi/Auto analysers, Calorimeters, emergency lights, water filters etc. The PHCs
are having patient’s privacy by provision of curtains, cots, mattresses in good condition. The
linen supplies were inadequate as three sets are provided per bed and during the rainy
season these supplies are inadequate.
30
(
In some states, quality of civil works leaves much scope for improvement and delays are
reported in undertaking or completing projects. Most states have set up or are in the process
of setting up an infrastructure or construction wing in an attempt to facilitate rapid
infrastructure development. A few states still do not have an infrastructure development plan.
Shortages of electricity and water supply still afflict facilities in many states but generators
obtained through the RKS funds have helped.
Systems of referral/emergency transport have been developed in most states but a few still do
not provide for this facilitation of access to life-saving services. There is also a constraint of
transport for field workers and the supervisory tasks of MOs.
Equity Issues
Several initiatives have been taken by the states for the poor and marginalized groups. Waive
of user fees and free supply of medicines is one of the prime strategies to ensure access of
services to the BPL families being adopted in all states. As long as user charges and
inadequacy of drug supplies exist, this is an essential measure. However, since evidence from
various parts of the world has shown that user fees act as barriers to access by the poor,
women and girls as well as other marginalized groups, its effectiveness needs to be assessed
to ensure equity. Almost every state mission has observed this problem in the nature of
persistent user fees and their impact on access:
The mission from Bihar reports, “In the district hospital, user charges for most services are
found to be generally high and they are even comparable to private hospitals. All BPL
cardholders are excluded from user charges. However for those poor who do not carry a BPL
card, the decision for exclusion is made at the level of civil surgeon on case-by-case basis.
One would wonder how many poor could access civil surgeon’s office to avail such benefits.”
“There is a need to do more here especially in exemption in user fees, more so for the
outsourced services. No user fees are charged from BPL families. Despite this and the JSY,
institutional deliveries amongst SC/ST are less than others and were found to be largely
performed by TBAs. Since travelling distances to access services is more difficult for these
sections of society strengthening sub centers and PHCs will contribute to equity in access and
availability of health services.”
Mechanisms for social insurance are being put in place to some extent but are in too much of
a flux for the teams to observe their benefits.
In Rajasthan, which had an effective
mechanism, it was found that, “Social protection scheme includes Rajasthan Swasthya Bima
Yojana, which involved premium subsidy provided from NRHM, and government hospitals
reimbursed by the state insurance department for free treatment given to BPL card holders.
This scheme was stopped by the launch of RSBY under the Ministry of Labour, under which
31
smart cards are printed, but the scheme is presently non-functional with no payment made to
the Insurance Company (ICICI-Lombard). Meanwhile the GoR launched a comprehensive
social insurance scheme, which included health called Bhamashah scheme but that was also
stopped because of the issue of non-compatibility of cards (with software support from
Infosys) with the RSBY software. So, presently the health insurance for protecting the poor
from catastrophic expenditure is non-functlonal.”
The CRM team found that “one of the commendable achievements of Tamil Nadu state is the
low out of pocket expenses incurred by rural in-patients (Rs.637) in comparison to Rs. 2610 in
Karnataka, Rs.2170 in Andhra Pradesh and Rs.2174 in Kerala. The accessibility of facilities
and service is very good in the plains for the rural, BPL and SC population. The services in
tribal areas are provided through MMUs and the residents* have sought for daily availability of
VHNs and weekly visits by MOs.”
Reflecting on the IPHS:
Finally, there is also the issue of imperatives of the high goals set by the IPHS. While it may
be possible for some non-high focus states to meet those standards, they seem to be skewing
the service structure by making states shift personnel to where the gaps are more as per the
IPHS, thereby away from the primary and into the secondary level facilities. While there is a
rationale for making ‘at least some facilities fully functional’ if it is not possible to do so for all,
the moot question is whether the quantum of human resources required by the IPHS is
essential for ensuring the basic service provisioning or is some of it useful only once the basic
service provisioning is in place for further improvement of quality and effectiveness.
Thus, there is an obvious need for rationalisation of health facilities in all the states, but more
so in those with major constraints. This includes consideration of the spatial distribution of
facilities, human resources and skills as well as equipment against the service guarantees
expected for each and every village and residential clusters within villages. The processes of
decentralized planning and implementation within the health service system must lead to such
a rationalization. Now that the planning and management systems are gearing up, and the
medical officers too are getting involved In decentralized planning for the Block/Dlstrlct/State
Action Plans annually, such steps will have to be part of the next phase of the NRHM if further
gains are to be obtained and the gains are to be sustained. Of course, this would have to
supplement the ongoing efforts at facility strengthening.
Facility strengthening is happening due to the improvements in infrastructure, infusion of
health care providers, the support from availability of funds at all levels and improved fund
32
flow, better data management and availability, as well as enhanced community mobilization
and facilitation of access to services.
Health Human Resources
A large number of health personnel have been added to the public health system under the
NRHM. This has been the singular most important system strengthening process, since in
previous decades infrastructure development projects such as the Health Systems
Development Projects, and programmes for service delivery such as the RCH-I, had been
undertaken but there had been little infusion of human resources. If anything there had been a
depletion of some health cadres, such as the MPW (M) and the needs for operationalising the
new infrastructure had enhanced the human resource gaps, such as of specialist doctors and
nurses. The NRHM brought renewed attention to the issue and requirements were identified in
terms of numbers of the various professionals and para-professionals, based on the
vacancies in the already sanctioned posts as well as new estimates for reaching the IPHS
specifications. Skill sets were also identified as needing renewal, reorientation or development
de novo. The CRM has once again highlighted the progress made on this front in the last two
years.
The CRM has also found that the human resource gap still remains the singular most
important challenge in strengthening the public health system and meeting the NRHM goals.
Medical professionals available in the country, especially specialists, are not joining the public
services. Some specialities, such as anaesthesia and psychiatry, have very few professionals
being produced in the country. Nursing colleges are far short of requirements, and ANMTraining Centres have been non-functional for about a decade in several states, leading to
non-availability of staff nurses and AN Ms for recruitment. Paramedical personnel such as
Laboratory Technicians are again too few, or not trained and registered as per standards. Few
of the cadres have an orientation or training in public health planning and management.
All states have taken steps in the last two years to deal with this problem, for meeting service
needs in the immediate and for long-term outputs. The results were evident: even in a well
functioning health system such as Kerala--MMany doctors, specialists and nurses have been
employed in hospitals, CHCs and PHCs under the NRHM on a contractual basis and they
have added to the services in these centers.”
In the high focus states, most SCs have two ANM, the second ANM being recruited under
TSP by the state government. The second ANM is generally located at an underserved area
and not at the Sub-centre itself. These are positive developments. All facilities had
pharmacists and lab technicians.
33
Consultants desired under SHRC are in place, and also SPMU, DPMU are functional.
Strengthening of District PMU is in progress and establishment of Block PMU is proposed.
One Block Accounts Manager is in position.
This situation has come about through a number of initiatives for recruitment, improving
working conditions and attracting personnel to the public services, in-service and pre-service
trainings for multi-skilling and multi-tasking of the present personnel as well as producing
more.
Recruitment
Procedures for recruitment have been simplified and powers delegated for local contractual
appointments; appointment of retired nurses on contractual posts, power of appointment given
to the THOs and medical superintendents, walk-in interviews. The Rural Medical Officer
(RMO) cadre has greatly increased availability of MOs at PNC level and this is a positive step.
The introduction of Compulsory Rural Service for MBBS and post-graduate doctors is a major
step in providing health care in rural areas.
Improving service conditions
The emoluments of cadres have been enhanced through several mechanisms. A 'hardship
allowance' Rs. 1000/- additional payment to nurses in tribal areas, Rs. 1500/- (both
contractual and regular) for those working in extremism affected division and Rs. 1500/-
additional to doctors working in extremism affected division.
“Entry level post for doctors upgraded to Jr. class - I, specialist pay increased form meager
Rs. 150/- to Rs. 3000/- per month. Additional allowances are being offered to doctors serving
in KBK districts Rs. 8000/- at block level and below, Rs. 5000 at district level, contractual
18,000/- instead of 12,000/-. Post-mortem allowance of Rs. 500/- per case
A proposal for
restructuring of cadre of doctors for creating better promotional avenues is under active
consideration. A rational transfer policy for doctors being formulated.”
“The state (Tamil Nadu) has standardized the rules and regulations for appointments,
transfers and promotions through annual counselling.
Pre-service educationltraining, In-service Training & Multi-skilling
The capacities of existing training institutions for intake numbers have been enhanced and
new colleges/centres are being set up. Under PPP all nursing schools to increase their
capacity. They would be provided beds from SDH/DH and PHCs, fees of Rs. 25,000/- to be
paid as loan for students entering into 5 year bond, monthly stipend for girls from tribal areas.
34
Three new medical colleges have been set up in the state. Additions have been made in the
under-graduate curriculum e.g. the IMNCI.
Multi-speciality training on priority of nurses/doctors posted in tribal and extremism affected
areas.
With multi-skilling of health care providers, one limitation has been the poor retention of skills
and performance based on the training. A process of review followed by modifications in the
selection of in-service candidates for the training has effectively to better retention and
performance, for instance in the case of LSAS in Orissa - 1st batch: Selection of trainees was
done by the CDMOs, retention and performance of trainees was low. 2nd batch: applications
were sought from in-services doctors; retention better but still low. 3rd batch: Applications
sought for specified FRUs, interviewed and counseled for selection of those interested.
Retention and performance review will include giving an honorarium if found to be practicing
LSAS.
However, many of the multi-skilled personnel like EmOC, LSAS trained doctors are not able to
perform due to various inherent systemic reasons.
There is also a shortage of training faculty and an added problem if the trainers are
transferred frequently. Frequent transfers can adversely affect a district since they may lose
trainers. In Dungarpur, 2 of the 4 Master Trainers of IMNCI have been recently transferred
severely affecting their training schedules.
Workforce management Issues:
The CRM teams have highlighted several workforce management issues that states need to
address: in designing and operationalising such HR measures:
Appropriate postings and transfers: Poorly planned transfers which lead to non-functioning
of human resource compelled by personal reasons. At Kuttichal PHC there was only one
doctor as doctors were said to be refusing to work in the area. However, according to the
doctor, his wife, also a doctor was posted in another district. Coordination in postings will help
the situation.
Rational/transparent transfer and postings policies & procedures need to be formulated and
operationalised.
Clear role definition: Within the system and for each person at a facility, there is need to
define the roles and responsibilities, “There is lack of clarity on role division between the two
35
FHWs and the one or two MHWs posted at a sub-centre. Outreach village or home visits do
not appear to be regular or as per a defined beat programme”.
Career progression opportunities: Career progression pathways and options need to
be buolt inot the system. “A system of bridge courses to upgrade ASHA to AWW to ANM to
Graduate Nurse and to Postgraduate Nurse should be set up as an incentive for better
performance and for career progression.
Rationalised and equitable emoluments: While planning for incentives and salaries, entire
staff in the hard areas needs to be considered at the same time, “ANMs under TSP are
contractual; drawing hardship allowance under NRHM in tribal/desert areas. Contractual LTs
(under RCH II) not drawing hardship allowance. The allowance is not available to DPMs and
BPMs either. These ‘anomalies’ were reported to the CRM.”
Training policy and planning: The teams noted the need for a comprehensive training policy
and infrastructure to enable ongoing training and re-training of personnel. “There is no system
of nursing in-service education for the state as a whole. This is the appropriate time to set it up
while the state is developing its human resources at a rapid pace.” For the presently planned
trainings e.g. SBA, IMNCI etc. also it was observed that the numbers were grossly inadequate
and a larger number of trainings requires to be undertaken.
Integration of contractual staff and regular cadre: mechanisms for integrating the new
contractual appointees into the state health services will be required to sustain the proegress
made under NRHM.
Community Processes in the National Rural Health Mission:
The National Rural Health Mission continues to expand the extent and quality of community
involvement. Significant progress has been made in addressing many of the gaps identified in
the first Common Review Mission Report.
The flagship of community participation is undoubtedly the ASHA programme. Emboldened by
its welcome in the high focus states of the NRHM, the programme was extended to cover all
states in October of 2008. Of the 13 states visited by the CRM, nine were high focus states
with the ASHA programme well in place and 3 were high performing states with ASHA
programme either limited to tribal areas - Karnataka and Maharashtra and Kerala . In only
one state Jamil nadu, has the programme yet to be initiated. In every one of the high focus
states visited ASHAs have been met with and the programme has been assessed with in
some detail. The reports are unanimous in the appreciation of the work being done by ASHAs,
their enthusiasm and their potential.
36
The Assam report states “ The ASHA programme has created a groundswell for NRHM in the
state, they are the face of the NRHM and have a visible and audible presence, with their
dresses, umbrellas, radio and JSY contact. They will now be given cycles, which will give
them a visible presence on rural roads.ASHAs are verily the wheels of NRHM in the
hinterland.”
The progress on some parameters which relate to what the system should do for supporting
her are not uniform and are facing constraints. Thus on training Chhattisgarh, Orissa, Assam,
Rajasthan, Madhya Pradesh have all completed their 4 modules or on the 4th training round
which represents about 15 to 19 days of training ( much more in Chhattisgarh), Uttar Pradesh,
Bihar and Mizoram however lag behind with only 7 days of training in each.
ASHA payments are reported as regular in Orissa, but in most other states there is a 3 to 6
month delay. The problems seem most acute in Jharkhand and Chhattisgarh.
Drug kits have been procured at distributed in all states except in UP and Bihar. This is a very
good progress since the last year when only one state had done so. However the challenge
now is to refill the drugs as and when they get exhausted- which means a very good system
of procurement and logistics and expanding the funding for this component both from central
and state budgets. More information on patterns of usage and financing would be essential as
also the task of improvement in logistics.
The other area where there is slow though steady improvement is in the support structure.
The district community mobiliser/coordinator is in place and in Chhattisgarh, in Orissa and in
Uttar Pradesh . Appointments are in process in Madhya Pradesh, Rajasthan, Jharkhand and
yet to be brought onto the agenda in Bihar. Sub-district facilitators are in place in Chhattisgarh
and in process in other states. A state level resource center providing support is critical, but
has been established in only three of the nine high focus states visited- Chhattisgarh, Orissa
and Jharkhand. There is considerable need for urgency in this area for without such support
experience shows that it is difficult to sustain outcomes from the programme. The Madhya
Pradesh team states “there is hardly any recognition or consideration of ASHA support by
state health department, and it was at large felt by the team during their interaction with
officials from SHCs, PHC, CHC and district health systems.”
One very encouraging feature reported from many states is a diversity of support and
encouragement activities like presentation of sarees, umbrellas, or radios or cycles to ASHAs
. In Assam a radio programme specifically beamed at ASHAs also provides support
On Village Health and Sanitation Committees, the programme has moved forward steadily.
The most time consuming step is the issue of an order at the state level stating the terms of
formation of these committees. Qnce this step is completed, the VHSCs are rolled out and the
37
funds transferred - the entire process taking a few months after that. This stage has been
reached in Kerala, Maharashtra, Tamilnadu, Mizoram, Chhattisgarh, Orissa and Uttar
Pradesh. In Jharkhand, Rajasthan, Madhya Pradesh, Assam the VHSCs are formed and the
programme is at the stage of fund transfer. In Bihar the snag is at the state level as the
enabling order is still to be issued. There is not enough information on what the funds have
been used for across the states but where funds have reached and guidelines are in place,
preliminary reports suggest that the money is well spent on a variety of local necessities- most
often related to drinking water or drainage.
The other major challenge is increasing the role of communities in management through
different instruments of decentralization. Of these the most universal and most functional are
the hospital development societies. This is functional in all states, though the role given to the
elected panchayat varies. In some states they had become solely a vehicle of user fee
collection. Under the NRHM the process of these societies as vehicles to provide space for
communities in governance and management and as a vehicle of improved facility level
decision making was emphasized. Upto now, much of the energy had gone into registering
them and making them functional. Now the mission notes it would need to be focused on
providing more space for user participation and making them more equity conscious and less
user fee dependent. As a rule where untied funds are given to an functional RKS and basic
guidelines are in place, these united funds get utilized well. This was the case in most states.
On the core challenge of communitisation, on the issue of the health facilities being placed
under the panchayats-on\y Kerala and Karnataka have such a situation in place. All the others
are able to involve panchayat leaders in all the four above steps- ASHA selection, use of
untied funds at the sub-center, the village health and sanitation committee and the RKS- but
this involvement stops short of actually reporting to them or being paid by them. In Bihar the
panchayat leadership role in the RKS is being stepped back and in Assam it is being headed
by local MLA.
NGO involvement in NRHM varies. In most states they participate in the MNGO scheme, the
ASHA scheme and in capacity building for VHSCs. The effectiveness of the MNGO scheme
needs to be studied further and though missions mention MNGOs in different roles, the
scheme itself does not draw attention. The one special form where community participation
and NGO involvement is very visible is in community monitoring. Of the states visited
community monitoring had taken place and where there was a positive response to it was in
Assam, Karanataka, Rajasthan and Chhattisgarh. Though the potential for replication is not
clear some reports suggest, “community monitoring can be beneficial if kept simple.” There is
possibly a need to persist with this and work on further approaches as well as a limited
scaling-up to fully understand the potential of this component.
38
9
In conclusion, the NRHM has brought the role of public participation in the health sector center
stage and multiplies the forms and intensity of community participation. This has no doubt
contributed to better utilization of services and better health awareness. The process of
decentralization and public participation in governance however remains a challenge.
Improved Management:
This has four distinct components: the induction of management skills and the strengthening
of existing management capacity, the building of better financial management systems, and
putting in place a robust health management information systems the creation of structures for
professional public health management and technical assistance. We consider below each of
these:
Induction of Management Skills:
Every state visited had put in place a team of contractual staff with management qualifications
for programme management (the district programme manager) and with IT qualifications for
data management and with financial qualifications for financial management. Only Tamil Nadu
which has a health administrative cadre had not done so, and Kerala had used these positions
for putting in place officers identified as more dynamic, from within the medical cadre itself.
One advance in this year over the previous is the coming into position of contractual block
management staff in Assam, Bihar, Chhattisgarh, Jharkhand, Karnataka and Kerala,
In most states, these cadres were performing well and had made themselves invaluable.
There was still the problem of integration of the contractual management staff with the regular
medical administrative directorate staff- but the problem is now articulated as a change that
needs to come in the directorate. The need for this contractual staff inputs is no longer in
question. The coordination of the directorate with the state mission directors office has now
become the central management challenge. There is no doubt that in terms of sustainability
and in terms of technical quality of the programme and even in effectiveness, personnel with
management functions under the directorate need to be better oriented, better qualified and
better supported to play a leadership role. But it is also clear that without the induction of new
blood, the stimulus to change the old styles of functioning, and move to a measurable
performance output mode of functioning is unlikely to occur. The deliberations of the National
Workshop on strengthening public health management (held at Puducherry) therefore assume
an immediate relevance for this discussion. The consensus arrived in that workshop could
inform the way management in the state directorates and in the districts are strengthened.
The CRM also points out that given the contribution this contractual staff is making there
should be more attention given to their human resource management- both in skill
39
development and also in performance review and incentivisation and increments in
compensation packages.
Systems of financial management:
There are four key dimensions of improvement in financial management
One is the addition of financial staff, especially at the block and district levels. This has
happened across the states. With NRHM has come the simple recognition that to handle the
vast volume of accounting at the district and block and even sub-block levels, a large number
of persons with accounting skills have to be inducted- and the lack of this was a critical
bottleneck.
The second change promoted successfully by NRHM is the e-transfer of funds to district level
and increasingly further down to block and facility level. This is a move that creates substantial
time savings and transparency.
A third major area of improvement is in the introduction of concurrent auditing. Here progress
has been slow. States like Madhya Pradesh, Kerala, Karnataka, have made strides forward in
this- but the other states continue to lag behind in this and would perhaps need more support
and persuasion to be able to put this in place. Monthly financial reporting has started has
however started up and is seen in most of the states reported and even this should be
computerized and web-enabled over the coming year.
But the fourth is the core improvement- the actual increase of expenditure with timely
submissions of audited statements and utilization certificates so that fund flow is streamlined.
Despite considerable increase in systems across the 13 states, it may be noted that the
poorest states- Bihar, Uttar Pradesh, Jharkhand, Chhattisgarh all continue to have a poor
absorptive capacity for funds- though it is precisely these states that need to expand their
public expenditures on health sharply.
HMIS and its effectiveness:
Progress in HMIS was assessed at a time when a major changeover of the system has just
been initiated. What the CRM has picked up were largely the current state of affairs and the
need for a paradigm shift.
Almost all state teams reported that the analysis and use of information is very weak. In most
states data collection however is ongoing and though there is much improvement in quality
needed, this is not the central problem. In many states computers are available in block level
and in all states they were available in the district level. In states like Kerala and Maharashtra
and Tamil Nadu they were available in the PHC level also. Some states had started entering
data into the web-portal, but at the time of visit most states had yet to do so. It was thus clear
40
that of all the many problems that HMIS faces the central, most widespread and persistent
problem is the poor analysis and use of the large amounts of data that is on flow and
secondary to this the problems of validity and reliability.
This poor use of data, noticed by all teams, is also related to design features. For one the use
of indicators instead of raw data elements generates “information" as different from “data” and
this facilitates the use of this information. Secondly the systems should be able to support
data analysis and display at every level, including the level of data entry. It should also have in
built feed back systems, as tools of programme management and improving data quality. And
thirdly it emphasizes the need for capacity building and the need for coordination at the
periphery between the IT specialist, the Public health practitioner and the demographer.
One other issue raised was that data usually bypassed the sector PHC and was aggregated
only at the block level. The need for training staff on this was noted by all. Persisting multiple
formats were reported by a few teams. Potentially this could be a major area of improvement
in the coming year and the spin-off effects of this turn key improvement on all aspects of
programme management could be immense- if we get it right.
Institutions of Management and of Change:
The other major thrust areas in management are the need for special vehicles for
management of procurement and logistics, an institutional structure to manage infrastructure
development, a revitalization of the state institutes of health and family welfare to lead in in service skill development and of the state health systems resource center to drive forward the
process of architectural correction.
Over a year of striving what seems to have been achieved is a broader understanding of why
such organizations are needed. However in terms of really getting them going on the groundthe progress has been decidedly modest.
Procurement and Logistics Organisation
The TNMSC model in principle has been accepted as the benchmark for an effective
procurement and logistics system. In this period, Kerala has also gone in for such a system
and Karnataka has made some major changes in this direction. Madhya Pradesh has
declared an existing agency- the Laghu Udyog Nigam as deemed to be its procurement
agency, but this agency is not coordinating logistics whiich, though an improvement falls far
short of the requirements. Orissa has set up a state drug management unit which streamlines
some aspects of procurement. Though many other states have committed to making such an
institutional change, few have actually done so. The benefits of a TNMSC like system for
improved governance and decreased wastage, to better availability of drugs and supplies , to
41
a higher per capita public expenditure on drugs, and a reduced out of pocket expenditure for
the poor patient at the public hospital are all well acknowledged and documented. The
urgency is to push harder for this fundamental change.
Infrastructure Management Organisation
In many states serious crisis of poor expenditures relates to money locked up in infrastructure
development. This is further compounded by the problem of poor quality of civil works and the
failure to make water and electricity arrangements as part of the same development costs.
There is evidence to show that a separate cell or unit charged with this task organized this
work with greater efficiency and speed. In this period Bihar and Madhya Pradesh has created
such a cell and Karnataka and Kerala have created engineering wings within the health
department. Given the huge gap in crucial health infrastructure there is a need to put such a
system in place, other states would need to give this much greater attention.
State Health Systems Resource Centers and SIHFWs
This is another key management strategy of the NRHM. This is an area where there has been
partial progress. Many states have recruited consultants for providing in house technical
assistance in many areas. Others have created centers for some of the functions- like
Jharkhand has created an outsourced Sahiyya resource center and Orissa has constructed a
community processes management unit within the SPMU. However
no state except
Chhattisgarh has a full fledged state health systems resource center in place. The CRM
identified many areas where states require technical assistance in many areas- in improving
quality of training, in better quality of district and state planning, in planning for child health
more effectively, in building up drug distribution systems, in designing BCC programmes, in
quality assurance programmes, in human resource planning , in building up health
management systems etc. Though these can be initiated with the help of external consultants
and agencies there is a need to build up technical capacities within the state to sustain and
develop these programmes further. If there is no self reliance built up in technical capacity the
long term sustainability of public health systems would be compromised. There is also a need
to institutionalize such technical capacity in an institution that the state supports so that there
can be an institutional capacity with institutional memory of the planning and development
process. This is distinct from the role of the SIHFW though these institutions can be
collocated. There is also a need to strengthen SIHFWs in most states, and indeed this area
would need a special review.
42
I^eccmmendaticns < f the
Seccnd Common Review /Hission
Recommendations of the Second Common Review Mission
6
1. Standardizing Nomenclature: Work with states to finalise a clear nomenclature for the
different facility levels and their hierarchical relationships to each other. This was not
an issue earlier, but now with central funding flowing to states to meet norms and a
monitoring system where this relationship is critical, confusion on names would be a
major constraint in planning, financing and monitoring. One aspect of this is defining a
sub-center as being embedded in every PHC and CHC, to look after the outreach
activities of the section where the facility is situated. This would alter calculations of
requirements for staff as distinguish between the facility’s outreach services and the
services provided in the facility premises.
2. Contextualising IPHS: Work with states to contextualize IPHS guidelines so as to be
able to plan and set meaningful annual targets for improvement to reach the goal of
service guarantees at every facility level in a phased approach. Contextualisation
should also mean review of guidelines to ensure that service priorities in each facility
level should reflect the epidemiological profile in each state.
3. Revitalizing the sector PHCs: Some states have shown that it is possible to place
Medical Officers at PHCs, such as Rajasthan and Tamil Nadu. Others could attempt to
reach this stage but, as a start ensure that at least the paramedical and nursing
personnel placed there are multi-skilled to provide primary level curative care as also
arrange at least for a visiting doctor. Pooling of medical officers at the CHC (block PHC
level) should not become a reason for collapsing the sector PHC which is essential for
the provision of many services.
4. Improving the quality of care and comfort of stay for the in-patients in the public
hospitals especially at the secondary level, through clean toilets, fresh linen, and a
friendly environment. Over time, move to a system of ensuring quality improvement in
all public health facilities.
5. Mainstreaming AYUSH not merely mainstreaming the AYUSH provider: The main
purpose of bringing AYUSH services to the mainstream facility is to provide users with
a greater choice of services. But using an AYUSH service provider to provide non
AYUSH services defeats the purpose- and needs to be restricted, even where the
provider may be willing to do so.
6. AYUSH providers in allopathic care: Where an AYUSH doctor is being used as a
substitute to a MBBS medical officer, there is in addition to the above, the need to
43
specify through standard protocols the level of care that can be provided by them and
provide them with the training and legal framework to provide such care.
7. Supporting the ASHA: There is a need to urgently strengthen the ASHA support
system. This includes a state level resource team capable of developing further state
specific training material, well trained and supported district and block level teams of
facilitators and a system of monitoring. Streamlining of payments also needs to be
strengthened and its base widened by allowing a larger number of activities to be
incentivized.
8. Pro-Poor RKS: Enhance community participation, especially representatives of user
groups in the hospital development committees (rogi kalyan samitis), and transform
their image from being a vehicle of user fee collection into an organization charged
with addressing equity and quality issues. This requires a greater awareness of the
limitations and problems of user fees and a greater willingness to exempt the poor or
where needed completely eliminate all but the most token forms of it.
9. Getting VHSCs going: Expedite the activation of village health and sanitation
committees and strengthen facilitation systems for this. In particular, NGOs could play
a major role in this.
10. Community Monitoring: Simplify the current process of community monitoring and
broad base the programme participants and expand on it. Ensure serious
consideration of the findings and issues raised; also view it as a process of dialogue
with the community.
11. Coordination at the top: Improve coordination between the health mission and the
directorates in the states and increase training and support inputs to directorate staff
so that they are able to participate and eventually lead in the process of change and
revitalization of public health systems.
12. New Institutions: Working with state governments to start up 3 management
organizations/ arrangements of minimum design specifications immediately - one of
these being for procurement and logistics, another for infrastructure and the third for
technical assistance (the SHSRCs). National workshops with groups of states with
similar situations to help them design organizational structures most suited to their
situations would be useful to move this process along.
44
13. Professionalising Management: Improving the quality of public health management
through the development of a public health sector management cadre, expansion of
public health education including in-service skill training and improved human resource
development policies for health administrators.
14. Improved Workforce Policies: Make improvement of workforce management policies
one of the cornerstones of good governance in the states and support states to move
to evolve and implement commonly agreed to policies in this regard. A state watch on
the performance of different indicators of good governance would be a useful
supplement.
15. Revitalising SIHFWs and Training Institutions: Assist and support states to draw up
and implement plans to revitalize their SIHFWs or equivalent organization and other
training institutions in the states so as to ensure that in-service skill upgradation meets
the quality and pace required to improve service delivery.
16. State Specific Human Resource Plans: Assist and support states to draw up and
implement state specific human resource development plans to expand with quality
medical, nursing and paramedical education, such that the needs of the public health
system are prioritized and met within the shortest time possible.
17. National Plan for faculty development: Build a national plan linked to the above to take
on the responsibility of developing faculty and quality assurance systems for this rapid
expansion in medical, nursing and paramedical education. This would be a very
valuable support for the low performing states and it would need assistance from the
high performing states, catalysed by the center.
18. State spending on human resource component should expand, so as to slowly take in
the new positions being created under NRHM.
This is needed for long term
sustainability, for establishing better work force policies for increasing the range of
incentives need to draw skilled human resources and retaining them in under-serviced
areas and for increasing states commitment to increased public health expenditure.
19. Resource Linked District Plans: Build on the district plans by linking district planning
efforts to a better understanding of resource envelopes that are being made available
to it. Also, on a more pragmatic level develop the practice of revising the plan
document after the national sanction and based on this making a state sanction to the
45
districts and place this revised post sanction district plan in the public domain as well
as use it to guide action.
20. District Plans to rationalize resource allocation: Develop the district plans further so
that this is used to rationalize infrastructure, human resource and financial resource
deployment to match utilization patterns of different facilities and areas.
21. There is a need to increase budgetary allocation to core system development issues,
even for maternal health. Much of the funds gets absorbed in Janini Suraksha Yojana.
There is a need to ensure, that there are proportionately adequate funds allocated and
expended in non JSY activities of RCH that prepare the facilities to deliver quality
services as well as address other dimensions of maternal health. Though much has
been done to ready facilities for the JSY inrush the rate of increase of JSY has
outpaced all of this. Expanding facilities and human resource to meet this increased
load of the most vulnerable becomes a national emergency. There is also a need to
focus on preparedness of facilities in providing neonatal care and meeting felt needs
for contraception.
22. Low human resource densities due to failure to create adequate facilities, due to failure
to create adequate number of posts in sanctioned facilities and due to failure to fill up
vacancies have all taken a toll on disease control programmes. The NRHM’s emphasis
on human resource development should take the needs of the disease control
programmes also into account. Currently even in key district level management
positions there are shortages of staff. The lack of integration of disease control
programmes in a district plan in a technically meaningful manner is also a challenge
that could lead to improved outcomes on many programme, but especially in vector
control. For these reasons and more every effort should be taken to further integrate
disease control programmes and IDSP into the NRHM so that these divisions are
convinced of the technical merits of such a decision. This is not yet happened at
district and often even at state levels.
23. While immunisation programmes have been given attention In states with regars to
outreach and fixed day services, gap in availability of vaccines and issues In cold chain
management, seems to have adversely affected progress in the current year. Lack of
minimum required facilities and human resource densities also contribute to limiting
progress in a significant way.
46
24. Going Beyond RCH: Progress beyond planning for RCH service delivery in primary
and secondary facilities to plan for addressing emergencies, acute illness and even
chronic illness into primary and secondary health care and through the development of
appropriate referral linkages and human resource development and deployment
strategies such that all the facilities within a district become like parts of a single
functional unit. In states which are high performing on RCH parameters this should
emerge as the immediate priority, but even in other states this is necessary to provide
considerable social protection for the poor from the increasing costs of care and also
to increase the effectiveness of all disease control programmes.
25. More flexibility to flexible funding: Improve the flexibility of fund allocation to facilities
within a district and to districts within a state so that funds flow to facilities and districts
which use them best. This is essential to expedite useful absorption of funds. However
when going into such flexible financing there is a need to ensure that the funds needed
to reach a minimum level of functioning are not .compromised and equity
considerations within regions are kept in mind- so that places already suffering for lack
of human resources and sanctioned facilities are not deprived even further.
26. Engaging with the private sector: Engage with the private sector to provide services in
thematic and geographic areas where the public system is deficient working out
packages that are cost effective and transparent and subject to good monitoring
practices. The experience so far has been very mixed. This review shows a multitude
of good partnerships with motivated, largely not for profit institutions, but there are few
examples of any link with the commercial private sector that are seen that could be
recommended for nation-wide replication.
27. Information for Action: The main challenge is to develop HMIS systems and capacities
so that action can be taken on information derived from data analysis at the facility and
at the sector, block and district level. This would also increase validity and reliability of
data collected nationally. The development of the national web-portal and the
rationalization though important milestones, must be seen as only initiating steps. The
main challenge is the development of district level systems and capacities for use of
information. The other major challenge is to be able to collect information from the
private sector as well.
47
I <mv issues across the states
A summary
State Reports in Brief
Key areas state-wise
Theme -1
Assessment of case load being handled by the system at all levels
State
Key Findings
1.
NRHM a revolution in access to health services. It has made a
huge difference. Significant increase in institutional births and
outpatient visits. Significant increase in IPD cases as well.
Evening OPD started in many places.
2
The increased utilization of services is reflected in increased
number of persons provided every type of service that is
available - be it outpatient care, be it in patient care, be it
institutional delivery services, be it emergency services, or
surgical services, lab services, etc. Every Block has a 24X7
facility with at least 6 doctors and nurses. Close monitoring
facilitates service guarantees. High case load in Block PHCs
and District/Sub District Hospitals. Additional PHCs still to be
made operational.
3.
ORD services and normal deliveries show increasing trend in
Health Sub Centres and CHCs. No increase in PHCs due to
shortage of doctors and nurses. Well functioning CHCs with
regular attendance of doctors has increasing indoor patients as
well. District Hospitals have increasing case load. Uneven
performance in family planning services.
4.
Evidence of increased case load at the Block PHCs in spite of
unsatisfactory basic infrastructure and hospital beds at that
level. Increased in patient load in District Hopsitals. Slight fall in
OPD in one District Hospital perhaps due to better functioning of
Block PHCs arid Sub Centres.
Sahiyyas very active.
Institutional deliveries yet to pick up on a very large scale. In
patient care also picking up with more functional facilities.
Assam
Bihar
Chhatisgarh
Jharkhand
Karnataka
5.
Institutional deliveries have increased from 60% in 2005 to 79%
in the current year - perhaps on account of JSY and State
Government initiatives like Madilu ( post natal care kits for BPL),
Prasuthi Ariake ( ANC benefits for BPL), etc. Many NRHM
initiatives are recent. OPD load suggests substantial increase in
case load at PHCs. District and Taluka Hospitals have high
48
case load. FRUs under utilized.
6.
Outpatient case load is god in all hospitals, CHCs and PHCs.
State wise data suggests that OP cases have shown increase in
2007-08. Inpatient cases are variable. Inpatient cases can
increase if full range of services is provided. Not all CHCs
providing 24X7 services. Wide variation among facilities and
their load. Need to focus on life style diseases (diabetes,
hypertension).
7.
NRHM represents a revolution. There is a significant increase in
IPD and OPD case load at health facilities. JSY has increased
the credibility and confidence of the people on the government
health institutions. There are trained and skilled manpower to
support health facilities at many institutions. Khargone, a tribal
district, has reached 71% institutional deliveries. Increase in
OPD and IPD has been so significant that a decision to increase
bed strength by 6000 beds has been taken in the State.
Kerala
Madhya Pradesh
8.
Definite improvement seen in the outpatient load of Sub centres,
PHCs and Rural Hospitals(CHCs). 24X7 Block PHCs are
offering outpatient, emergency and institutional services. Sub
Centres are regularly doing deliveries (labour room construction
has increased numbers). Increase in in patient load due to JSY
as also facility upgradation, clean toilets, water availability,
inverter for alternate source of electricity, free meals and also
due to feel good factor generated by the beautification of the
centres with NRHM funds. Sub District Hospitals need
improvement..
9.
IPD/OPD attendance appears to be the same over the last three
years. Presence of Regular Medical Officers has made positive
impact on IPD/OPD in PHCs. Little Sub Centre delivery. ANM
doing home delivery. Increase in institutional delivery at
PHC/CHC after JSY. Utilization of delivery facility at District
Hospital has gone up but up gradation is not commensurate
with the increased load.
Maharashtra
Mizoram
Orissa
10.
NRHM has transformed public health service delivery in the
State. The decentralization, responsiveness to local needs,
paradigm shift in health system management and availability of
untied funds has improved the facilities and their credibility
among members of the public. JSY, community mobilization by
ASHAs, and proper referral transport have contributed to a large
extent in increasing the case load. However, greater patient
load has been noted in the district, sub district hospitals and
CHCs as compared to PHCs and Sub Centres. Increased
number of deliveries, OPDs and bed occupancy reported from
49
the districts visited. Sub Centres weak, limited services.
Rajasthan
11.
Increase in institutional deliveries. Almost all PHCs reporting
institutional deliveries. Some Sub Health Centres also
conducting institutional deliveries. Well performing Health
facilities attracting increased case load, cases of malnutrition
and large number of non communicable disease cases as well.
12.
Since the inception of NRHM, the PHC case load has increased
remarkably - daily OPD by 17% and inpatients excluding
deliveries by over 100%. The average Op attendance is 60 to
230 in the PHC. Discharge two ays’ after deliveries and diet is
supplied through SHGs. The SDHs and DHs are well equipped.
13.
NRHM has infused a new life into the flagging health sector in
UP. Huge upsurge in institutional deliveries. Sub Centre has
one ANM but active in most places. OPDS also show increasing
trend because of better maintained facilities. District Hospitals
very well maintained. Some CHCs have also started providing
surgical services. Increase in 24X7 PHCs.
Tamil Nadu
Uttar Pradesh
50
Theme - II
Preparedness of health facilities for patient care and utilization of
services
State
Key Findings
1.
While human resource has increased, there is a still a long way
to go in fully preparing facilities for all kinds of morbidities.
Physical infrastructure and availability of ambulances has
improved. Blood storage arrangement not functional in many
First Referral Units. Family Planning services need more
attention. Basic diagnostic tests being done - need to provide
for a larger range of test services. Need for better equipped
emergency rooms. Shortage of drugs. Need to expand range of
services in Village Health and Nutrition Day.
2
Patient satisfaction was in almost all places very positive - the
recent memory of a complete lack of services and the current
changed situation being upper most in people’s minds. Provider
qualification was more qualified, but even then, on the whole,
very positive. ‘The workload has increased so much but there is
little improvement in staff or facilities to manage the increased
workload.’ The system is in danger of stabilizing at a low level of
expectations and outputs. Increase in services up to the Block
PHC level. Additional PHCs still a big challenge - very poorly
functional. APHC works like a Sub Centre with an outpatient
dispensary.
3.
Improvement has taken place in Health Sub Centres, CHCs and
District Hospitals. PHCs are the weakest link. CHCs not
providing First Referral Unit services in most places.
Improvement with untied grants in infrastructure, equipments,
drug supply, water supply, contractual staff etc. Unsatisfactory
utilization of ambulance services. Lab facilities functional with
minimal services. Large human resource shortages affecting
preparedness, besides irrational placements.
Assam
Bihar
Chhatisgarh
Jharkhand
4.
Sahiyyas have been trained up to third module and have drug
kits with them. ANMs are in place at the Sub Centre with basic
facilities like BP equipment, stethoscope, etc. Immunization
through VHNDs is a priority. Medicine availability at Block PHC
and District Hospitals has improved leading to higher case load.
Doctors on contract besides the regular doctors at PHCs and
Additional PHCs. Many of them providing service 24X7 in spite
of a various adverse housing facility in remote areas. Poor
infrastructure is a serious concern. While large scale new
construction has started under NRHM and the Finance
51
Commission grants, it will take some time before they are all
completed.
Karnataka
5.
Concerted efforts to improve the health facilities from funds from
different sources. Availability of untied funds has made a
significant difference in the preparedness of health facilities at
all levels. While facilities are well equipped, utilization services
is not very high in PHC/CHC.
6.
Uneven preparedness of facilities leading to uneven utilization
rates. Assured services can reduce congestion in higher order
facilities.
7.
Facilities do not have staff as per Indian Public Health
Standards norm. District Hospitals were adequately staffed. The
Specialists at CHCs and blood storage facilities there need
priority attention. Janani Express vehicles in all FRUs help in
referral transport. Lab services available in all facilities. Keeping
in view the sudden increase in patient load especially under JSY
scheme, the infrastructure in terms of staff and other facilities
are under a great strain which is affecting adversely the quality
of service and has reduced attention to other programmes.
Mobile Health Units doing well.
Kerala
Madhya Pradesh
8.
Extremely committed health functionaries in coordination with
public representatives have been ale to deliver good quality
services. 30% PHCs have reached IPH Standards. Nurses,
doctors and Specialists have been appointed. Well stocked
drugs and consumables, laboratory facilites for conducting
diagnostic tests. Water quality checking at Sub Centres. Blood
storage facility in IPHS PHC and CHC.
9.
Medicos and Para medics available at all levels - except
Specialists. Young doctors in position, appear confident and
capable of handling most conditions. Need to better utilize time
of health workers at Sub Centres. District Hospitals better
equipped. Some equipment not fully utilized. Lack of Specialist
manpower at CHC. All PHCs well equipped in lab facilities with
regular tests being done. Rapid Diagnostic kits with ASHAs but
not with health workers. All facilities well maintained with proper
cleanliness, disposal pits constructed ( using RKS funds) paramedical and Group D staff trained in IMEP at District
Hospital.
Maharashtra
Mizoram
Orissa
10.
Urgent need to up grade infrastructure. Inadequate budget for
drugs leading to out of pocket expenses. Utilization of untied
funds, maintenance grants and RKS grants to improve
preparedness of health facilities was very impressive in both
districts. 1153 AYUSH doctors at PHCs and CHCs to provide
52
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pH - II 0
Ut>S1
pog
OPD services. Substitution rather than co location in the
absence of the MBBS doctor in PHC (N).
11.
Sub Centres getting prepared for institutional deliveries with
labour rooms. Good institutions attracting high load. Large
number of surgeries in District and Sub District Hospitals.
Significant number of non communicable diseases are being
identified and treated at primary and referral levels. PHCs and
CHCs handling larger case load and prepared to do so. All
PHCs have an MBBS doctor and 40% have an AYUSH doctor
as well.
12.
The PHCs, Block PHCs, upgraded PHCs, Sub District Hospitals
and District Hospitals are adequately equipped for the routine
works and emergency situations. All the facilities are provided
with adequate number of Specialists, Doctors, Nurses, VHNs,
Pharmacists, Lab Technicians, and other support personnel on
regular, service placement or contract basis. The PHCs, SDH,
and DH are able to meet the requirements for lab investigations,
x-ray, ECG, ultrasonogram, etc. All Sub Centres and PHCs are
provided with requisite drugs and other supplies. Need to
improve quarters at PHCs.
13.
While cleanliness has improved, shortages of Nurses, Doctors,
Specialists hampers preparedness to deliver quality care.
Rationalization of posting and stable tenures needed for
preparedness to improve further. Need to focus on expansion of
nursing services. Sub Centes and PHCs have started using
untied grants. More than half the ASHAs are very active in the
community. Village Health and Sanitation Committees have
been set up though getting the cooperation of PRIs is proving
difficult in many areas.
Rajasthan
Tamil Nadu
Uttar Pradesh
53
Theme - III
Quality of services provided
1.
State
Key Findings
Assam
Substantial improvement in infrastructure. Need for further
improvement of quality and range of services. Wards were patient
friendly with clean linen, sufficient lighting and clean toilets.
Segregation of waste with deep burial. Complaints about CHCs
have reduced as they are functioning well.
2
Over 100% Bed occupancy in District Hospitals. Lack of nurses and
mid wives hampers quality of care. Mamta programme for women
volunteers in hospitals is an innovation to meet the nursing
shortages in hospitals. Additional of more trained and well
supported nurses into the system would be the single most
important step that could be done to improve quality. Lack of beds
and nurses in Block PHCs. Excellent outsourced ambulance service
helps in shifting patients. Conversion to 30 bed PHCs is needed on
a priority wherever more than 5 deliveries take place every day.
Standards of cleanliness would require substantial improvement. In
all facilities visited there are efforts to improve amenities - lighting,
wiring, water supply, patient waiting halls, toilets, drainage, etc. but
these are rather sporadic. Need to use untied funds at all levels.
There is a systematic effort to provide generator support, pathology
diagnostics, x-ray and soon ultrasound as well, ambulance
services, laundry services, diet services and cleanliness and
sanitation services. Need to monitor outsourcing arrangements
more effectively to ensure full compliance to agreements.
3.
Health Sub Centres are giving better services than in the past,
thanks to untied funds and their proper utilization. Functional
telephones at all Health Sub Centres. Mitanin help desk in health
facilities is a good initiative in bringing poor households to facilities.
CHCs and District Hospitals provide bed nets to protect from
mosquitoes. Infection control measures have started but pits are
provided only in a few places.
Bihar
Chhattisgarh
Jharkhand
4.
5.
Karnataka
Block PHCs are basically six bed hospitals with very modest basic
features. New buildings will take a little time for completion. OP
services have improved due to availability of medicines. Contract
doctors have improved availability of human resources. Shortages
of nurses. Sub Centres are quite well equipped though own building
is a constraint. Sahiyyas are active though performance based
payments are not timely.
Staff Nurse and Medical Officer availability has increased. Drugs
largely available. Quality Assurance thrust in Tumkur leading to
54
efficient use of untied funds. Untied funds being used imaginatively
for client convenience - TV, Plants, CD players, waiting halls, etc.
More attention needed on toilets - not very clean. School Health
programme improving access.
Kerala
6.
Wide variation in the quality of services between similar type of
institution. Related to the motivation, commitment and skill of the
head of the facility. PHC buildings have been renovated. TVs and
DVD facilities in many hospitals in Wynad district. Display of list of
medicines. Need to monitor seh/ices from the point of input versus
services.
Madhya Pradesh
NABH accreditation for District Hospitals is under way. Quality
assurance is receiving attention in the system.
8.
Maharashtra
Sub Centres well equipped with infrastructure and equipments and
untied funds. Hospitals have become women friendly. Clean and
well equipped labour rooms. Waste management satisfactory.
Panchayat representatives involved.
9.
Mizoram
PHCs and Sub Centres are well managed. Cleanliness is good.
District Hospital needs improved facilities.
7.
10.
Overall some improvements have been made in the services like
cleanliness, waste collection, electrification, water supply but are
inadequate. While there were extra sweepers appointed from untied
funds and maintenance grants, there is still scope for improvement
in the cleanliness of toilets and availability of water supply in some
hospitals.
11.
Most institutions have received a face lift with the untied funds of
NRHM. Toilets were clean and functional and many CHCs had
functional power back ups. CHCs are still not able to provide
Caesarean section service. Blood storage is an issue. No or limited
surgeries at CHCs. Waste segregation and facility level disposal are
being done at most institutions; pits were found to be constructed
and in use; bio medial waste was being brought back from outreach
sessions.
Orissa
Rajasthan
12.
13.
Tamil Nadu
Almost all facilities are well maintained and upkeep of facilities is of
satisfactory levels. Family Health Clinics in all 385 Basic
Emergency Obstetric Centres thrice a week.
Uttar Pradesh
Nursing cadre shortages hampers quality of care. Women not
staying 48 hours after delivery. While cleanliness and basic
infrastructure improvements have improved the quality of services,
quality of care requires far greater thrust on nursing services.
55
Theme - IV
Utilization of diagnostic facilities and their effectiveness
1.
2
State
Key Findings
Assam
Range of diagnostic services available at various levels has
improved substantially. Much more needs to be done to improve
the technical skills of the Lab. Technicians.
Bihar
Diagnostic services through PPPs. Outsourcing by contracting in
private providers. Private partner not showing that much interest
at operating it at the Block level. Non availability of regular Lab
technicians. Inadequate attention to quality and biomedical waste
management.
Chhatisgarh
3.
District Hospitals and CHCs have functional laboratory facilities.
Not functional in PHCs due to lack of manpower. Pregnancy
testing kits and rapid diagnostic kits are available in most
facilities. Convergence of lab services of RNTCP, general health
services and vector borne diseases.
4.
TB Programme Lab Technicians at a nu,ber of Block PHCs.
Integration of lab services is taking a little time. Diagnostic centres
being established in District Hospitals. Modern equipments
procured or in the process of being procured.
5.
7 Regional diagnostic labs under the Karnataka Health System
Development project. Lab Technicians are largely in place with
adequate equipments and reagents. X- ray and ultra sound at
Taluk Hospital. Water testing facilites. Lab investigations for ANC
not available at PHC. No RTI/STI testing. Utilization of diagnostic
equipments by ANMs at Sub Centre is low.
Jharkhand
Karnataka
6.
Kerala
State has appointed Bio Medical Engineers to ensure that the
equipments are in working condition. Overall the equipments are
good.
7.
Madhya Pradesh
In most of the facilities one Lab Technician is available for doing
all the investigations for all the programmes.
8.
Maharashtra
All 24X7 PHCs are provided with lab providing basic facilities.
Semi auto analyzer, ECG, X ray facilities. Services at reasonable
user cost. 30 Public Health Lab services for water quality
monitoring, industrial waste/effluents examination, etc.
9.
Mizoram
Diagnostic facilities available but not as per Indian Public Health
Standards. Need for proper maintenance strategy for equipments.
Need to build strong accountability of suppliers at purchase stage
56
10.
Orissa
There was an effective pooling of Lab Technicians from malaria,
TB, NIV/AIDS for efficient handling of investigations and
diagnostic workload in the DH/SDH/CHC level. Lab facilities are
not available in PHC ( N).
11.
Rajasthan
Lab services suffer from staff shortages. Rapid Diagnostic Kits for
malaria, IDD kits and haemoglobin kits available with ANMs.
Pregnancy testing kits available with ANMs and ASHAs.
12.
Tamil Nadu
The essential investigations are available in all PHCs, Sub District
Hospitals and District Hospitals. The Block PHCs are provided
with scan and all the 235 upgraded PHCs are provided with
ultrasonogram, x-ray, ECG and semi auto analyzer. Blood storage
facility in 20 PHCs by TANSACS.
13.
Uttar Pradesh
Lab Technicians are available for basic tests. Need for better
coordination and convergence among all the programmes.
57
Theme - V
Drugs and supplies
State
Key Findings
Less than satisfactory in 2008-09. Medicine availability in
1.
Assam
2006-07 an 07-08 was better. Supplies expected to improve
December 2008 onwards.
Improved supply of essential drugs is the most notable
achievement by the State and this has significantly
contributed to the increased use of public facilities noted
during the past few years. The new rate contracting system
and enforcing presence the presence of distribution depots of
2
3.
4.
Bihar
the suppliers within the State through which the districts place
orders, has tremendously improved the availability of
essential drugs at public facilities. At least 15 drugs were
available in most PHCs. Sub Centres without drugs. Local
procurement to meet stockouts. Per capita expenditure on
drugs is Rupees 8 after steep increase. Needs to
substantially increased with improved availability of drugs at
Sub t Centres as well. Logistic systems need to be fully
operationalized.
Chhatisgarh
State level e- procurement is in place. Some delays in
supplies. Proper mechanism for receipt, storage and
indenting of drugs. Need for warehouses at district level.
Availability of drugs is satisfactory. Occasional replenishment
by Jeevan Deep Samiti is made. Mitanins got drugs but
delays in replenishment. Recent efforts at streamlining
equipment management.
Jharkhand
Rate contract system with funds being released to PHCs.
Availability has improved considerably at all levels. Sahiyyas
have also been given medicine kits but arrangements for
replenishment is not in place. Essential drug list and standard
treatment protocols has been prepared for the state.
A State Drugs, Logistics and Warehousing Society has been
5.
Karnataka
established that acts as an official procurement agency to
meet all requirements pf health and family welfare
department. Indents collected at the beginning of year. Rate
contracts after call for tenders. 14 Drug warehouses in the
State. 14 more taken up for construction. Use of untied funds
to procure drugs in case of shortage has helped. A very
sound procurement system with very few stock outs. Need for
review of drug list to make it more rational. ASHA drug kit
58
replenishment needs attention.
6.
Setting up of the Kerala Medical Services Corporation is a
major step. Operation from April 2008. process of
procurement and distribution of medicines and supplies has
been streamlined. Computerization, pass book system and
essential drug list has been established. Systematic and
regular testing of all batches of medicines. Need to
standardize the indenting procedure. Need to increase
storage space.
7.
The State has developed a drug policy. TNMSC model is
being implemented in the State. Separate drug cell has been
formed and Laghu Udyog Nigam has been appointed as
procurement support agency. Procurement through e tendering has reduced cost of supplies and improved quality.
Distribution of procured medicines and materials is done
through outsourced warehouses. 21 warehouses are under
construction under NRHM funds.
Kerala
Madhya Pradesh
Maharashtra
8.
Drugs and supplies are in abundance in the Sub Centres,
PHCs and in CHCs. They are well stocked in newly made
racks and cupboards with proper marking for easy retrieval.
Vaccines are also available ( except measles) and in proper
condition stored in I PL and deep freezer.
Mizoram
Medicines are centrally procured and distributed based on
indents. There are shortages. Need for effective inventory
management.
Orissa
Most of the health facilities had drugs and pharmaceuticals
available as per allocations but the budget per facility is
inadequate and needs to be enhanced. A State Drug
Management Unit has been set up for procurement of
medicines and this has improved timely procurement and
availability. However, mechanism for transparency and need
based distribution of drugs to districts/facilities is yet to be put
in place. Emergency drug tray was found to be adequately
stocked in most facilities.
11.
Rajasthan
Generic drugs available in Hospitals and facilities at 30-50%
lower than MRP through cooperative stores. List and price of
generic drugs displayed in all facilities. ASHAs provided drug
kit. Replenishment from Sub Centre. Indenting needs to be
more timely to prevent stock out situations. Shortage of high
cost antibiotics for weeks. Injectables and fluids show no
stock out.
12.
Tamil Nadu
Role model supply system of TNMSC. It is very effective in
9.
10.
59
ensuring adequate supplies of drugs and other routine
supplies of all health facilities. EC Pills and IUDs are not
available.
13.
Uttar Pradesh
While drugs are available, the allocation of drugs is very less
compared to the need on a per capita basis. There is a need
to increase the drug budget and develop sound system of
logistics, inventory management and forecasting. Preparation
of essential drug lists and use of generic drugs needs to be
encouraged alongside efforts to set up TNMSC like
corporation for procurement and logistics of drugs and
equipments.
60
Theme VI
Health human resource planning
1.
State
Key Findings
Assam
There are shortages of doctors and para medics and efforts
have been made to rationalize through regular posting and by
contractual appointments. Incentives have worked for the
contractual but there is resentment among the regular
doctors - need for incentives for regular staff and for career
progression. Need to rationalize placement of ANMs. Many
ANMs at higher level institutions. Need for cadre review of
doctors and paramedics to retain good human resource.
2
The availability of human resources has increased
substantially in Health Sub Centres, PHCs, DHs and Medical
Colleges. Shortage of Specialists, Nurses and Lab
Technicians still exist. Very innovative new cadre rules have
been approved for doctors with well defined career
progression. Contractual appointment policy is in place. Need
to improve and expand nursing education as a top most
priority.
3.
Chhatisgarh has serious human resource shortages. Lack of
rational and transparent transfer and posting further
aggravate the problem. Recent effort to post Rural Medical
Assistants in difficult areas from the 3 year course students.
Large scale shortages of Nurses, Lab Technicians Para
medics, Specialists.
4.
Large scale shortages of Specialists and Nurses. Efforts have
been made to rationalize postings of Specialists at Block, Sub
District and District Hospitals. Need to create Specialist cadre
and undertake rational and transparent policy of transfers and
postings. Gradation list not yet prepared in Jharkhand state
leading to lack of transparent criteria in key postings of
doctors. State needs to look at Bihar’s new cadre rules and
create a similar system. ANM School and Nursing schools
need further strengthening with increase in intake. Jharkhand
has a tradition of nursing services and women workers
migrating in search of work. Nursing will improve skill levels
of migrant women workers. 1200 doctors being recruited
through the Jharkhand Public Service Commission.
Appointment in final stage.
Bihar
Chhatisgarh
Jharkhand
5.
Karnataka
Medical doctors, para medics, nurses reasonable available in
facilities visited. Contract appointment of Specialists, Doctors,
staff nurses, ANMs and Lab Technicians has been made to
61
meet shortfall. In sourcing in FRUs. MBBS doctors trained in
Emergency Obstetric care and life saving anaesthetic skills
have been posted to designated FRUs. Signs of improvement
in availability of HR. ANM Training Centre need attention. A
cadre management and service condition of doctors is an
issue.
6.
Various category of human resources have been added on
contract under NRHM and this has added to services.
Medical Officers as DPM working well. Compulsory Rural
Service for MBBS and Specialists is a good step. NRHM
Coordinators not integrated into health system. More rational
systems of deployment needed.
7.
Madhya Pradesh
There are large scale shortages of Specialsts and Nurses in
the State. Contractual support structures for programme
management are in place at the State and the district level.
The block level structure is being put in place.
Maharashtra
Several steps to improve availability of Nurses. Second
ANMs provided. MPW Male already there. Shortage of
Anaesthetists. Need to rationalize posting of Specialists to
ensure service guarantees. Capacity of government nursing
schools has been developed. Decentralized appointment on
contract. Multi speciality training on priority for nurses posted
in tribal and extremist affected pockets. Higher payments in
tribal and naxal areas.
Mizoram
Availability of doctors and nurses has increased due to
contractual appointment in NRHM. Specialist shortages
persist. 2 ANMs in Sub Centres. Need for in service nursing
education. Need to invest in mobility of non doctor
supervisors as well. Increased staffing of Lab technicians
leading to increase in service availability.
Kerala
8.
9.
Orissa
10.
11.
Rajasthan
Shortage of MBBS doctors, Staff Nurses, Specialists and Lab
Technicians plague public health services. The State has
taken several immediate and long term initiatives to meet this
HR crisis in the State. 3 new Medical Colleges have been set
up in the private sector. Cadre reforms and up gradation of
entry level post of doctors as Junior Class -I plus allowances
in difficult areas likely to attract more doctors. Cadre
restructuring under active consideration. Multi-skilling going
on. Proposal for 8 GNM Schools and 13 ANM Training
Centres.
Shortage of Specialist at FRU/CHC. The Rural Medical
Officer cadre has greatly increased availability of MOs at
PHC level. Shortage of Lady MOs. Multi-skilling under
62
progress - needs to be utilized better. 2 ANM in tribal areas
is a very good development. Very few refresher courses for
ANMs. Need for synergy among training institutions.
12.
During the last two years 4263 nurses were appointed on
contract basis in the rural health centres. Life saving
Anaesthesia skills imparted to 106 MBBS doctors who are
posted back to Block PHCs. All VHNs given Mobile Phones.
Cadre reforms to promote posting in rural areas. Satisfactory
HR position.
13.
Human resource is the real challenge in UP. Huge shortage
of Nurses and Specialists. Some rationalization Is improving
availability of services of Anaesthetists and Gynaecologists.
This alone will not be enough. Need to expand nursing and
medical education sevices on a large scale. Some District
Hospitals could be considered for up gradation in to Medical
Colleges in a time bound manner. Three year courses as in
Assam and Chhatisgarh could be considered.
Tamil Nadu
Uttar Pradesh
63
Theme VII
Infrastructure
1.
2
3.
State
Key Findings
Assam
While lot of buildings have been constructed or are under
construction, there is a need for greater rationalization of
capital investments in order to ensure full utilization. While
facility surveys have been completed, the up gradation is
often not based on felt-needs.
Bihar
Infrastructure wing under the State Health Society has been
created. Progress on construction is tardy. State exploring
options for faster pace of construction and maintenance.
Quality supervision of construction is weak.
Chhatisgarh
Unsatisfactory infrastructure.
PWD and
Chhatisgarh
Infrastructure Development Corporation doing buildings. Lot
to be done. Many Sub Centres in rented buildings. Many new
construction works are under progress.
A very unsatisfactory infrastructure. Large scale construction
4.
Jharkhand
has been taken up in the last six months which will take a few
more months for completion. It is likely to improve the
position for infrastructure. Block level PHCs need up
gradation into 30 bedded CHCs on a priority. Accommodation
for doctors and nurses also needs priority attention.
5.
State is pooling infrastructure resources from different
sources. Impressive physical lay out of PHCs/Taluka
Hospitals, and newly constructed Sub Centres. Need to focus
on quality of construction in a few places. Facility Surveys
undertaken and gaps identified. Engineering Cell of Health
Department doing the construction.
6.
Building and equipment infrastructure coming from many
sources. Engineering wing of NRHM Kerala for planning and
monitoring. Equipment bought should be audited for their
utilization. A State wide emergency ambulance system needs
to be established.
7.
Madhya Pradesh
Infrastructure Wing has been established under the Health
Department and large scale construction works have been
undertaken. 1747 Sub Centre buildings, 193 PHC buildings,
101 CHC buildings, and 7 District Hospital buildings are
under construction at present.
8.
Maharashtra
Karnataka
Kerala
Excellent
construction
of
new
infrastructure
and
64
repair/upgradation of the existing infrastructure. Gardens and
landscaping. Staff Quarters in good condition.
Mizoram
Construction cell in NRHM Directorate is over stretched due
to the volume of work. Need for assessing need for
engineers. Local people’s committees may be involved.
10.
Orissa
Huge backlog of construction activities un der NRHM and
State funds. A separate engineering unit set up last year.
Work allotted to 8 Governement PSUs. Progress
unsatisfactory. Need to prioritize Health Sub Centre
construction along with ANM’s residential quarter.
11.
Rajasthan
Good progress in construction. Emphasis to construction of
residential quarters at PHCs/CHCs is a positive step. Out of
pocket expense for referral transport.
Tamil Nadu
All the PNC premises have a new look as most of the civil
works have been completed. Need to improve residential
quarters. Need for an infrastructure division within the health
department as PWD has many other responsibilities.
Uttar Pradesh
Infrastructure in District Hospitals, CHCs and OHCs has
vastly improved in the last few years. There is a lot more to
be done. Construction is going on at many places. A large
number of Health Sub Centres need new buildings or repair.
Site selection for PHCs must be near habitation for their
optimal use.
Large gaps in infrastructure need to be
addressed on a priority.
9.
12.
13.
65
Theme VIII
Empowerment for effective decentralization and flexibility for local
action
1.
State
Key Findings
Assam
20,309 VHSCs formed. Started late due to PRI elections.
Need for capacity building. Rogi kalyan samitis in most
places. Good community participation in programmes. Village
Health and Nutrition Days have attracted community
participation.
2
Panchayats are represented in the RKSs and the District
Health Society. Involvement of Panchayats in NRHM is still
not a priority. RKSs have been formed and are functional.
VHSCs not formed as yet. Block Health Manager and Data
Assistant working under the RKS. District Health Society
meets regularly and proceedings are well maintained.
3.
Good participation of Panchayati Raj Institutions in the
decentralization agenda. VHSCs constituted under the
umbrella of the PRIs. Jeevan Deep Samitis in facilties. Good
use of untied grants in 2008-09. PRIs need to be made more
active in Jeeevan Deep Samitis.
Bihar
Chhatisgarh
4.
Panchayat elections have ot been held in Jharkhand since
1978. There are no elected PRIs. Therefore NGOs have
been enlisted in selection of Sahiyyas and in the constitution
of the Viigae Health Committees. Wherever the NGO
selection has been a good one, the performance of the
Sahiyyas and the Village Health Committees has been good.
In other places, selection of NGO has hampered local
processes. Procurement of drugs, untied grants to local
institutions, has helped in the process of decentralization.
5.
PRIs are on board. Members of Panchayats as members of
Arogya Samitis. CEO of Zila Parishad in District Health
Society. All facilities from the Taluka downwards are funded
thorugh the Panchayat system. Indifference to health among
Panchayat members perceived by doctors, leading to
delayed decision making. Good use of untied funds at all
levels. District Health Society meets regularly.
Jharkhand
Karnataka
6.
Kerala
Ward Health and Sanitation Committees have been
operationalized. Untied, annual maintenance grants and RKS
funds being regularly used to upgrade facilities and services.
PRIs are part of RKS and are involved. Panchayats are
66
involved in the running of Sub Centres.
Madhya Pradesh
VHSCs being formed and accounts being opened. Not fully
operational as yet. RKS in all facilities. Untied funds being
used under direction of ANM. Need to improve the
involvement of the Sarpanch.
8.
Excellent involvement and cooperation of PRIs. VHSCs are
fully functional. Untied funds used for cleanliness and
beautification. SHGs involved in providing meals in PHCs.
ANM providing meals to delivery cases at Sub centre. RKS
meetings are held regularly. Sarpanch, members of VHSC,
Gramsabha, and employees of health panchayat and ICDS
involved. In preparation of Village Health Plans.
9.
Village Health and Sanitation Committees operationalized in
all villages. Active involvement of youth, women and senior
citizen groups in activities such a s awareness for malaria,
improved sanitation, etc. Need for regular meeting and
monitoring of financial progress. RKS operational with active
involvement of Village Council members. Good use of untied
funds. District Health Society meetings not regular.
10.
Orissa
Untied funds at different levels have contributed significantly
to addressing local needs effectively and towards
empowerment of local action and convergence. 11774
VHSCs set up ( Gaon Kalyan Samiti). NGOs supporting the
process. PRIs, women’s SHGs and ICDS AWWs are being
involved in the functioning of RKS, GKS and in the health
system.
Rajasthan
Untied funds being utilized at all levels - the pace of
utilization needs to increase. MRS formed at all levels.
VHSCs formed but their money is still with the Sub health
Centre. Need to make VHSCs more active.
Tamil Nadu
VHSCs established for 12,618 villages and 2540 town
panchayats. VHSCs meeting regularly and the record of
discussions are maintained. Untied funds well utilized. Patient
Welfare Societies in PHCs. Active District Health Missions.
Need for empowerment of DMHOs. Community monitoring in
a few facilities.
Uttar Pradesh
PRI sa re involved but health functionaries complain of non cooperation in many places. Village Health and Sanitation
Committees have been set up under the umbrella of PRI. Sub
Centres have joint accounts.
Maharashtra
Mizoram
11.
12.
13.
e
67
Theme IX
ASHA
State
Key Findings
Assam
26,225 ASHAS have completed Module IV training. ASHA
programme has created a groundswell for NRHM and ASHAs
are the visible and audible presence. JSY work popular. Most
of them earned less than Rs. 10,000 in one year. Medicine
kits provided but no arrangement for replenishment. Popular
weekly radio programme.
Bihar
ASHA programme is in place and the ASHAs are almost
without exception, enthusiastic and functional. In most
facilities they were seen in the labour rooms and maternity
wards with the patients they had accompanied. Delays in
performance based payments. Training for 2-4th module is
delayed. ASHA programme is doing well in spite of the
constraints. Succeeding due to local innovations. The
Muskaan programme and the JBSY provide specific task for
ASHAs.
Chhatisgarh
60,000 Mitanins in Chhatisgarh. Trained and deployed in
every hamlet. Active in the field. Wide appreciation of
Mitanins role in society. Comprehensive support structures.
Mitanin help desks in all CHCs and District Hospitals. High
degree of skills and competence among Mitanins. Irregular
replenishment of drugs. Competition with ANMs for family
planning incentives.
Jharkhand
The Sahiyyas of Jharkhand have been selected by NGOs,
through Village Health Committees. They have done three
modules of training. Good modules have been developed in
the local contexts. Medicine kits have been made available to
them. Sahiyyas see themselves as a representative of the
local community and not as an administrative assistant of the
ANM. This has helped in keeping their community links
strong. Performance based payment processes need
streamlining.
5.
Karnataka
2150 ASHAs are in place in C category districts. Well
designed training programme for ASHAs. ASHAs have ID
cards. Need to create support systems for ASHAs. More
communication material needed for ASHAs.
6.
Kerala
8435 ASHAs in place. Selected by Panchayats. ASHAs
confident and aware of the NRHM programme. Performance
basd payment made regularly. Need to increase performance
1.
2
3.
4.
o
68
based payment criteria. Regular drug kits still to be provided.
8.
Madhya Pradesh
ASHAs are effective and knowledgeable. Accompanies JSY
cases. Reource Persons at the District level for training.
ASHAs involved in making blood smear slides in fever cases.
Incentives not worked out for malaria work. Some issues of
relationaship of ASHAs/AWWs/ANMs. Need for more NGO
involvement in the ASHA programme.
Maharashtra
ASHAs working in tribal areas. Third module training going
on. ASHAs are well motivated and enjoy the confidence of
the community. Block level ASHA libraries established in
three Blocks.
Mizoram
9.
ASHAs are active. Rapid Diagnostic kits for malaria provided
to them. Facilitate community leadership.
10.
Orissa
34,252 ASHAs selected. Induction training completed for all.
48% ASHAS have comleted up to fourth module. ASHAs
provided with drug kits. Posters providing details of ASHAs
payments displayed in all facilities. ASHAs weer found to be
rooted in the community, highly motivated, and the
comp[etnecies and skills were good. Good teams work with
women SHGs and AWWs. Role in nutrition and women’s
empowerment.
11.
Rajasthan
ASHA Sahyoginis are of the ICDS programme and their
involvement in institutional deliveries, etc. is low. Closely
linked to Aanganwadi Workers. The involvement of ANMs
with ASHAs needs strengthening. 15 day training for ASHA
Sahyogini - State may like to assess need for change.
12.
Tamil Nadu
Not implemented in Tamil Nadu as yet.
Uttar Pradesh
More than half the ASHAs are very active in the field. The
community knows them and uses their support in seeking
health services. Two rounds of training has been completed.
Performance based payment criteria needs to be widened to
include a larger number of activities for performance based
payments. Training needs to be speeded up. Role clarity vis
a-sis ANM and AWW will help. ASHA is a key person in the
Village Health and Sanitation Committee.
13.
a
69
Theme -X
Systems of financial management
1.
2.
State
Key Findings
Assam
The capacity of the State to utilize funds made available to it
under various components of NRHM has consistently
increased. Good State level leadership and active role of
District Health Missions. Need to improve financial record
keeping. District PMUs have good data. Need to strengthen
capacity at State level. Civil works and tender process take a
little time and that is fund utilization takes a little time.
Chhatisgarh
Though State Health Society account is opened, many
disease control programmes still operating through old
accounts. State share process initiated but not transferred to
State Health Society as yet. Audit of 2007-08 completed.
Core banking from District to Block level. Slow progress on
approved activities in 2008-09.
Jharkhand
3.
Karnataka
5.
6.
7.
Delegation of administrative and financial powers in February
2008. Accounts with SBl and SBM. FMG constituted.
Electronic transfer of funds from State to district. Single audit
report in the State. Concurrent audit in place in 6 districts.
Kerala
E banking facility across the State. The facility is operational,
and allows for transparency, audit and speed of operations.
ASHAs given electronic cards for financial transactions.
Madhya Pradesh
Expenditure reporting found to be satisfactory. Monthly Audit
of District Accounts and reporting by e-mail has helped. Use
of computers in PHCs. Substantial increase in utilization of
funds.
Maharashtra
8.
Mizoram
9.
Vacancies at the Block and district levels have al been filled
up Efforts to strengthen the state level set up has also been
made. Financial performance has improved and levels of
expenditure has picked up with large scale construction
activity.
Societies have merged. SPMU and DPMUs are functional.
Block Monitoring Committee in place. FMG at State level
providing guidance to field units. Timely reporting of financial
statements.
System of financial management in place with specific
personnel at various facilities. Delays in JSY payments.
70
Orissa
Increased pace of utilization of funds. Financial reporting is
timely. Transfer of funds through e-banking. Financial
guidelines under NRHM disseminated to all districts.
11.
Rajasthan
Finance team strengthened at all levels. Electronic transfer of
funds up to Block levels. Monthly financial reporting from
Blocks to districts, districts to States has been initiated. Tally
software has been introduced but use is at nascent stage.
12.
Tamil Nadu
E transfer of funds to districts. Untied grants released to all.
VHSC members need to be trained regarding accounting
procedures.
Uttar Pradesh
DPMUs have been established recently. Block and PHO level
staff strengthening needed for better financial management.
E - transfers to districts with the support of SBI. Need to
further streamline processes of reporting and their timeliness.
10.
13.
<
71
Theme - XI
HMIS and its effectiveness
State
Key Findings
Assam
Data system is weak. Information is collected but rarely
analyzed. State has partially operationalized the web based
district data system. Post 2005 the Data Manager at the
district has a lot of data.
Bihar
Data Centres at State,, district and Block level. Outsourced
system. Daily information is available. Cellphone connectivity
has also been established. Holds everyone in the system
responsible. A little over intrusive but then it serves the
purpose.
Chhatisgarh
Data generation through Block level, bypassing PHCs. New
formats being used in State level reporting. Most
programmes retaining vertical reporting formats. Feedback
mechanism not in place to improve the MIS process. Sub
Centres have up to date records.
4.
Jharkhand
While basic data is being collected manually, its analysis and
utilization varies. Need to create a strong HMIS for monitoring
performance of facilities, especially surgical procedures at
Block level facilities.
5.
Karnataka
Detailed State proforma. Web based system introduced in
one district. HMIS needs to be harmonized with NRHM
needs. Need for training staff.
6.
Kerala
The current manual HMIS is not meeting the need. The State
in process of developing new HMIS. Need for Nodal
information officers at each level. CHCs and PHCs have
computers.
7.
Madhya Pradesh
HMIS operational. Need to make it more effective with
capacity building at all levels.
8.
Maharashtra
Very well functioning web based HMIS formats, user friendly
software for data entry, analysis and report generation at
different levels and trained health staff in use of software
database are the features of the State HMIS.
9.
Mizoram
HMIS data being collected. Not stable as yet. New staff
deployed.
10.
Orissa
Comprehensive HMIS reporting formats have been
introduced since April 2007. Need to improve quality of data.
1.
2
3.
72
Feedback to PHC and Sub Centre needs to be strengthened.
11.
Rajastha
Integrated HMIS is in pilot phase covering RCH, IDSP and
NDCPs. Data validation build into the system. Testing phase
is over. To be expanded State wide in 2009-10.
12.
Tamil Nadu
Has good MIS. Computers in PHCs.
Uttar Pradesh
13.
Weak area in UP. Data is collected but not adequately
analysed at the right level. Efforts needed to ensure that the
new web based HMIS takes deep roots early and facilitates
analysis at each level.
73
Theme - XII
Community processes under NRHM
1.
2
3.
4.
State
Key Findings
Assam
Need greater support and capacity building. RKS functional.
VHSCs constituted. PRIS involved at each stage but greater
efforts at capacity building is needed.. NGO sector needs to
be involved more.
Bihar
While access to services at Block PHC has considerably
increased, the formation of community process institutions
like the Village Health and Sanitation Committees, Sub
Centre level committees, etc, is still pending. Rogi kalyan
samitis have been formed in most health facilities.
Chhatisgarh
92% VHSCs already constituted and accounts in the joint
signature of Mitanin and Panchayat Secretary has been
opened. Low utilization of funds so far. Monthly Village Health
and Nutrition Melas being held. Mitanins working in tandem
with ANM,
SHGs, etc. Community monitoring has
been initiated.
Jharkhand
Largely led by the NGOs through the Sahiyya programme.
Large presence of NGOs has helped. Rogi kalyan samitis
have been formed. Sub Centres are utilizing their untied
grants.
Karnataka
5.
Kerala
6.
7.
8.
Community monitoring through VHSCs in four districts, with
support from Karuna Trust. Need for more effective systems
of monitoring. Simplify village report card. Evidence of PRI
members say in use of untied funds.
Ward health and Sanitation Committees meet regularly and
maintain minutes. Panchayats provide fund for electricity,
medicines and glucometer. Need to orient Panchayat
members about NRHM.
Madhya Pradesh
Satisfactory involvement of the local communities and PRIs in
RKS and other institutions. ASHAs are effective. Indicates
useful selection criteria.
Maharashtra
7887 ASHAs in tribal areas. ASHA selection in other areas
has started. Support mechanism for ASHAs in place. VHSCs
established in 82 % villages. Maximum utilization of village
health funds is on providing safe water supply and thereafter
on Village health and Nutrition Day.
74
Mizoram
9.
Orissa
Community processes are strong. ASHA selection, role of
PRIs in GKS and RKS, Village Health and nutrition Days
have all created platforms for community action.
Rajasthan
Begun involving VHSCs in microplanning. Involvement of
community representatives in management structures needs
to be further increased. NGO programme is weak.
Tamil Nadu
Strong community participation through VHSC, RKS, etc.
10.
11.
12.
Uttar Pradesh
13.
ASHA in place everywhere. 7 day training. Need for refresher
training. ASHA mentoring group has met only once. Needs to
meet more often. VHSC operational in every village. Need to
involve other than health department functionaries.
PRIs are involved. RKSs have been set up. VHSCs have
been set up. Need for training of PRI/community leaders to
improve their contribution in decentralized management of
health system.
a
75
'i
f
Theme-XIII
Assessment of non-governmental partnerships for public health goals
State
Key Findings
Assam
NGOs involved in Boat Clinics - doing very well. NGOs in
community monitoring programme. There could be greater
involvement.
Bihar
The mother NGO programme is not operational. The State has a
number of PPPs. It has very little Ngo involvement at pr3esent.
Efforts to run APHCs through NGOs has not been very successful
so far.
3.
Chhatisgarh
State Health Resource Centre playing a key role in community
based health sector reforms. Playing a creative capacity building
role in many areas. Large scale NGO partnerships in the Mitanin
programme, blindness control programme, MNGOs and FNGOs
for RCH. NGO Jana Swasthya Sahyog running very good hospital
in Bilaspur district.
4.
Jharkhand
Sahiya programme and Mobile Medical Units have made use
NGO presence. MMUs are run by Vikas Bharati. Doing very well
with wide coverage.
5.
Karnataka
Large scale involvement of NGOs. 49 PHCs outsourced to NGOs.
6.
Kerala
Few NGOs involved. Community monitoring is not formally
introduced.
7.
Madhya Pradesh
1.
4
2
8.
9.
Maharashtra
Large scale involvement of NGOs in programme. MMUs by
NGOs. Training and capacity development through NGOs.
Community monitoring through NGOs. NGOs working for TB/
HIV/AIDS.
Mizoram
Active village level involvement of youth, women and senior
citizens through VHSC. MMUs provided to some NGOs. Mother
Ngo scheme to strengthen government efforts. Young Mizos
Asociation and Mizo Women’s Association are active.
>
Orissa
10.
Need to further increase NGO involvement.
Good NGO participation in NRHM activities. NGOs involved in
ASHA training, community processes for setting up of GKS in a
campaign mode, referral transport and management of a few
PHC(N) as a PPP arrangement, PRI sensitization, organizing
health melas, etc. 17 MNGOs and 88 FNGOs cover 2891 villages
in 22 districts under the MNGO programme.
76
11.
Rajasthan
Clearly spelt out NGO and PPP policy in the State. EMRI
ambulance service, MMUs, social marketing of sanitary products
as examples.
12.
Tamil Nadu
Donations to hospitals as PPP. Many local initiatives.
13.
Uttar Pradesh
Very few partnerships. Need for building detailed criteria that
facilitates NGO involvement. PPPs being proposed for Medical
Colleges.
9
<
77
/
Theme-XIV
Systems in place for outreach activities of Sub Centre
State
Key Findings
Some of the Sub Centres in the State were found to be
functioning very well with a resident ANM, high quality
buildings and good use of untied funds. Variation across
1.
Assam
centres. Many Sub Centres in rented buildings. Non resident
ANM in many places. Need to speed up Sub Centre
construction. 108 Ambulance system operationalized in a few
districts. The Male Worker is needed at the Sub centre level.
2
ANMs in place In Sub Centres. Untied funds given but not yet
utilized. Need more confidence to spend. Engaged in the
Muskan programme.
3.
Chhatisgarh
Besides VHNDs, biannual child health months has led to
significant increase in coverage of outreach services. While
ambulances are available, their utilization for referral cases
was low.
4.
Jharkhand
Sub Centres are doing better than in the past. VHCs are
getting active and funds have started reaching them. Mobile
Medical Unit has expanded access in remote areas.
Bihar
Streamlined outreach through fixed monthly putreach plans.
5.
6.
Karnataka
VHNDs getting institutionalized. Mobile Health Units
operational in KHSDP. EMRI planned for emergency
ambulance service across the State. Health Workers ( Male)
being trained..
Kerala
WHNDs are regularly observed. IEC materials are innovative
and well displayed. Sub Centre kit supply needs to be
regular. EC pills not available. JPHNs need periodic training
to cover all aspects.
Madhya Pradesh
Village Health and Nutriton Days effective. Sub Centres doing
outreach services. Need to widen land include larger public
health challenges as well.
8.
Maharashtra
9.
Mizoram
Fixed day services in village for iummunization. Village
Health and Nutrition Days.
VHNDs held regularly - more educational rather than service
function. MMU operational under District Hospital.
78
10.
Orissa
Fixed Village Health and Nutrition Days are increasing ANC
registrations, immunization, growth monitoring and nutrition
counseling activities. Mobile Units are in olace. Second
ANMs have been provided for outreach activities in remote
areas. Absence of MPW Male limits the actities.
11.
Rajasthan
Coordination with AWW is god as Sahayogini is a ICDS
functionary. VHNDs held regularly.
12.
Tamil Nadu
100 Mobile Medical Units with 100 doctors on contract.
63,715 camps in 2007-8. Effective school health programme.
Uttar Pradesh
Sub Centres need the MPW Male and the second ANM. The
load on a single ANM is heavy. Fixed day services have
started with good results. Mobile Medical Units to improve
outreach services yet to begin.
13.
79
Theme - XV
Thrust on difficult areas and vulnerable social groups
State
Key Findings
1.
Assam
Special efforts are being made to address health needs of tea
estate workers and people living in tribal and char areas. Need for
a robust plan. There is the challenge of attracting good human
resource in remote areas.
2
Bihar
Exemption from user fee needed for the poor.
Chhatisgarh
Chhatisgarh has difficult areas. Proposal for creation of Rural
Medical Corps with special pay to address remote area needs,
waiting for Cabinet approval. Rural Medical Assistants have
already been posted in tribal areas.
4.
Jharkhand
Tribal areas with large area with active Naxal issues. Difficult
working conditions for doctors and apra medics. Many of them are
providing service in these difficult areas. Untied funds has helped
them to activate the health facility and make it clean. VHC and
Sahiyyas have helped in improving the outreach of services.
5.
Karnataka
219 PHCs identified as remote. Additional financial incentives to
doctors and staff nurses. Priority to C category and tribal districts
is commendable.
6.
Kerala
Tribals form 1.14% of State’s population. ASHAs in tribal areas.
Sickle cell anaemia project targeted at tribal population.
Comprehensive Health Care Scheme for tribals provides for full
reimbursement.
7.
Madhya Pradesh
Mobile Health Units in tribal areas has helped. Need for more
focused attention. More direct publicity of free services for the
BPL/SC/ST needs to be highlighted.
8.
Maharashtra
Tribal area focus in ASHA programme. Additional financial
incentives for tribal and naxal areas. MMUs in difficult areas.
9.
Mizoram
Mizoram has difficult and remote areas that need special
initiatives. Perhaps efforts like NGOs managing remote PHCs ( as
tried out in Arunachal Pradesh) could be tried out in Mizoram.
10.
Orissa
Needs to be more pro- actively sought and encouraged.. Special
provisions for KBK districts.
11.
Rajasthan
Tribal Sub Plan provides for additional funding in diffuclt areas. 2
ANMs in difficult areas.
3.
)
80
12.
Tamil Nadu
Accessibility and availability of services is very good. Good
outreach through MMUs.
13.
Uttar Pradesh
Need to expand outreach services through camps. More nurses
and Male Health Workers needed in the field.
81
Theme - XVI
The preventive and promotive health aspects with special reference
to Inter-sectoral convergence and effect on social determinants of
health
State
Key Findings
Newly
elected
Panchayat
members
an
opportunity
for
convergence. Road map for their capacity building is needed.
Need for more involvement of health department functionaries in
inter sectoral convergence.
1.
Assam
2
Bihar
Nutrition rehabilitation programmes have begun. Emphasis on the
Vitamin A campaign.
3.
Chhatisgarh
AYUSH co - location has not happened as yet. Intra health sector
convergence is also an issue in Chhatisgarh.
4.
Jharkhand
VHNDs arer popular. Rapid Diagnostic kit for malaria has helped.
ANMs have these kits.
5.
Karnataka
Good convergence with NACP - III and ICDS in VHND. Water
quality monitoring being undertaken. PPP for vector surveillance.
WHNDs are regularly observed. United funds of WHSC used for
6.
7.
Kerala
Madhya Pradesh
source reduction and vector control. The absence of malaria,
filarial, dengue and Chikanguniya this year may indicate success
of such activities.
Greater community led
promotive health.
action
needed for preventive and
8.
Maharashtra
School Health Programme ( 353 teams at Taluka level) in
coordination with education department, geriatric schme
implemented in cooperation with volunteers from Kishori Shakti
Yojana and senior citizens attending the sessions at
Aanganwadis and doing exercise, constitution of VHSCs in
partnership with the water and sanitation committees, VHSC
funds for improvement of amenities in Aanganwadi Centres, safe
water supply, RKS funds utilized for drinking water facility, viable
partnership with ICDS through ASHAs in tribal areas, 438 Child
Development Centres to treat Grade - III and Grade IV
malnutrition, partnership with Public Health Labs for water quality
testing, are all an affirmation of the convergence in the State.
9.
Mizoram
Measures of vector control are good with involvement of VHSCs.
82
Convergent efforts in the VHNDs. Need for dental services.
NRHM implementation has clearly contributed to better linkages
of health staff with ICDS, Total Sanitation Campaigns and Self
Help Groups. The team work of ASHAs, AWWs and ANMs in
organizing the Village Health and Nutrition Day is a good platform
for convergence.
10.
Orissa
11.
Rajasthan
Need for greater coordination.
12.
Tamil Nadu
Good coordination at the field level.
Uttar Pradesh
School Health Programme and Saloni programme for adolescent
girls has been started. The Village health and Sanitation
Committee can also greatly enlarge preventive health thrust.
Need for systematic capacity building.
13.
83
Theme - XVII
Effectiveness of the disease control programmes including vector
control programmes
State
Key Findings
Assam
Thrust is on RCH. Gains in disease control programmes are
incidental. Malaria cases and deaths have reduced mainly due to
use of rapid diagnostic kits and insecticide treated bed nets.
ASHAS are trained in use of Rapid Diagnostic Kit and in blood
slide making. TB abd leprosy programme reported to be doing
well. No district tlevel laboratory under IDSP.
Bihar
Disease control programmes now with the Directorate. In the
absence of adequate financial delegation the programme has
slowed down. Technical protocols need to be more widely
discussed. Supply of anti kalazar drugs has improved.
Inconsistency in treatment protocols. Need for doctors’ orientation
on programme treatment guidelines. One round of spray for
vector control. Social mobilization of communities needs to be
speeded up. Case detection less than 50% for TB. Cataract
surgeries are not being regularly undertaken in District Hospitals.
No shortage of leprosy drugs reported. IDSP is just starting.
3.
Chhatisgarh
Section wise GIS mapping for malaria. 1,55,620 bednets
distributed in 2007. Rapid Diagnostic Kits distributed in Bilaspur
and Dhamtari. Mitanins trained in using Rapid Diagnostic Kits and
in making blood slides. Vacancy of MPW Male affecting Malaria
surveillance. Though malaria infected, District Malaria Officers
and Inspectors are not there. Poor monitoring of NLEP.
Inequitable and insufficient distribution of eye surgeons.
4.
Jharkhand
TB programme has picked up and services are available. Rapid
Diagnostic kits have helped in timely detection of falciparum
cases. In patient cases of malaria seen.
5.
Karnataka
Good progress on the disease control programmes. API has
reduced and deaths are low. Convergence of NVBDCP, TB and
HIV/AIDS noticed at PHC/CHC level. Vision centres are
functional. IDSP working very well.
6.
Kerala
Commendable that State has set up innovative programme for the
community to manage terminal illness. Use of NGOsA/olunteers
for pain and palliative care is commendable.
7.
Madhya Pradesh
Thrust on RCH activities. Need for wider public health focus to
cover all disease control programmes as well.
1.
2
84
8.
Maharashtra
Well run. Good coordination with NRHM. Rapid diagnostic kits
and other testing facilities available. ASHAs in tribal areas taking
blood slides of malaria. RNTCP has linkages with all ICTC and
ART centres.
9.
Mizoram
Malaria control programme is effective. Fevour and malaria cases
have come fdown. RNTCP doing well. Blindness programme is
less active because of lower awareness.
Orissa
High incidence of malaria but no District Malaria Officers.
Absence of MPW Male makes it difficult. MPW being appointed
on contract. Time take for reporting cases by laboratory is three
weeks to one month. Insecticide treated bed net useful but in
short supply. GKS needs to be involved in the vector control
activities actively.
11.
Rajasthan
Malaria areas well provided with active search and malaria drugs.
Rapid Diagnostic Kits being used in PHCs but not by ANM/ASHA.
TB detection and cure rates above the targeted levels. I DSP
formats at District/CHC/FRU levels.
12.
Tamil Nadu
Working very well.
13.
Uttar Pradesh
Still functioning separately. Need for integration. Need for
improvement in the Malaria control programme.
10.
85
Theme - XVIII
Performance of maternal health, child health, and family planning
activities seen In terms of availability of quality services at various
levels
State
Key Findings
Assam
Large number of new bom care centres at PHCs. Utilization
still low. Institutional births up to 60% from 37% before NRHM
started. Home births need attention as well. Full coverage of
immunization has improved.
2
Bihar
Access to maternal, child and family planning services has
expanded. However, unmet need remains high. The Muskan
Abhiyan for immunization and institutional deliveries seems to
have worked well.
3.
Chhatisgarh
Institutional deliveries yet to catch up. More needed to be
done on child health. Nutrition not a priority as yet.
Jharkhand
JSY yet to pick up. Institutional deliveries are slow to pick up
even though ANC registration has increased. More
confidence needed in the health facility and its service
guarantee. Sub Centre deliveries are taking place.
5.
Karnataka
PHC Taluka Hpsitals have shown improvement in physical
infrastructure to deliver RCH services. New born care needs
attention. SBA training, MTP and LSAS needs quality
assurance. Training of EmOC and LSAS for Medical Officers
has shown good progress though coverage needs to be
widened. Special efforts to simplify BPL certification has
helped. E banking has improved efficiency of JSY payments.
Improvement in immunization coverage is visible. Maternal
deaths are being investigated.
6.
Kerala
PHCs, CHCs, Taluka Hospitals providing services for family
planning. Only few CHCs providing 24X7 delivery services.
Public awareness of JSY and immunization is satisfactory.
7.
Madhya Pradesh
Substantial increase in institutional deliveries. Efforts made in
child health as well. . Improvement in family planning
services.
1.
4.
8.
Maharashtra
Significant increase in institutional deliveries, good quality
facilities and cleanliness contributes to popularity of the public
system. Simultaneous attention to maternal and child health
needs as also malnutrition. Pregnancy testing kits are
86
available in Sub Centres.
Mizoram
ANC done regularly at all facilities. Incidence of low birth
weight is very low. Need to improve new born care facilties in
CHCs and PHCs. Regular immunization at all centres. High
offtake of oral pill for family planning. EC pills not available.
Young doctors trained in minilap providing services at
PHC/CHC. Quality of IUD services could be improved. .
Orissa
PHC strengthening needs to be emphasized for preventive
and curative services. Thrust on CHCs/SDH and DHs. 61%
of all institutional deliveries in 2007-08 were JSY supported.
Major gains made. Quality of maternal care needs immediate
attention. Discharge within few hours of the delivery. 341
institutions that have been selected for 24X7 services need to
be operationalized on a priority basis. FRU operationalization
needs to be given priority. Childhood illness care at primary
level needs strengthening. Nutrition Rehabilitation Centres in
two districts. Contraception performance has improved
marginally. NSV achievements are impressive. Increase in
incomplete abortions coming for referral.
11.
Rajasthan
While maternal health has received attention, child health
needs more focused attention, especially neo natal mortality.
Need for birthing kit in JSY delivery centres. Shortage of
vaccines this year.
12.
Tamil Nadu
Excellent MCH services. Pending JSY payments. Increase in
family planning services at PHC level.
13.
Uttar Pradesh
Upsurge in institutional deliveries. Thrust on Child Care
programmes. Family Planning services need improvement,
especially IUDs and emergency oral pill availability.
9.
10.
87
Theme - XIX
Assessment of programme management structure at district and
state level
State
Key Findings
1.
Assam
149 BPMs, 149 BAMs, 454 PHC Accountants in place. Need
for coordination between NRHM and the Directorate of
Health. PMUs at all levels playing a significant role in
planning and monitoring. Most of them are young and
enthusiastic. The regular cadre of health personnel still not
fully involved. Cleavages between public health system and
NRHM.
2
Bihar
Programme management units at State, district and Block
levels. These units are functioning well. Need to expand
supportive supervision.
3.
Chhatisgarh
SPMU/DPMU In place. Need for more coordination with the
Directorates in an effective and efficient way. Block level
Programme Management teams being put in place.
4.
Jharkhand
SPMU, DPMU and BPMU has helped the programme in
developing a system at the field level. Need for closer
integration with the mainstream health administration.
5.
Karnataka
SPMU/DPMU is in position. BPM appointments in process.
Merger of NRHM and KHSDP enhances efficiency.
6.
Kerala
SPMU and DPMU functional. Block Coordinators in each
Block. More integration of Directorate may help.
Madhya Pradesh
State and District Health Societies
functioning with management skills.
established
and
8.
Maharashtra
SPMUs and DPMUs ae fully functional. Taluka Health Offices
strengthened with additional human resources. Directorate
staff fully involved in programme implementation.
9.
Mizoram
SPMU and DPMUs inplace. State Programme Manager to
join shortly. Presence is a strong support to the district health
administration.
10.
Orissa
SPMU strong. Good working ethos. DPMUs active,
professional and vibrant. Good team work with district and
block medical teams exist in the State. The
professionalization of health systems management inNRHM
in Orissa has been a major factor in enabling the paradigm
shift and effective decentralization of health management.
88
District Health Action Plans prepared by the district teams.
Rajasthan
SPMU DPMU structure is well established and provides
useful support to the programme. Need for closer integration
of the Directorate of Health activities.
12.
Tamil Nadu
Implementation of the programme in the State is exemplary.
The District Health Mission meetings are not being held as
envisaged under NRHM. There is no DPMU and BPMU as
yet. Block PHC has an Offfice Superintendent. DMHO from
the public hea;th cadre.
13.
Uttar Pradesh
SPMU is active. DPMU and BPMU being set up. These skills
are acutely needed. Divisional PMUs have been set with
SIFPSA support.
11.
89
Summary Renerts < f findings
from each state
ASSAM
THE REVIEW TEAM:
1.
2.
3.
4.
5.
Dr.Tarun Seem,Director,Nirman Bhavan,New Delhi
Dr. Dr Anil Kumar, CMO, Nirman Bhawan, New Delhi
Ms.N.Angami MSG.Covenor &Ex-President,Oking Hospital,Kohima,Nagaland
Sh. Gerard La Forgia, World Bank,New Delhi
Sh.Shyam Astekar.ASHA Monitoring group,School of Health,Nasik
THE DISTRICTS/ INSTITUTIONS VISITED:
1. Savisagar District
2. Bongaigaon District
Progress under NRHM
Areas of improvement
• Increase in general utilization of OPD and
indoor services, institutional delivery, and
immunization.
• Improved infrastructure, ambulance
and
logistics: construction of new PHCs, proper
Cold Chain maintenance, waste management.
•VHSC, RKS, instituted at village and facility
level.
•ASHAs are active, involved in VHND, JSY and
immunization activities.
•NGO participation in RKS and Community
monitoring.
•Weekly radio programme popular.
•Dibrugarh boat clinic is a good initiative for
island communities.
•Special efforts being made for services to tea
plantation workers.
• Malaria cases and deaths have reduced
mainly due to use of rapid diagnostic kits and
insecticide treated ed nets.
• Strengthening Delivery services: still
weak in SC and non existing at night in
PHC
•Further strengthening of infrastructure,
drug supply, emergency facilities, OT,
blood storage facilities, lab services,
mental health services.
• Incentive disbursement of JSY, HR policy
and rational postings of specialists,
performance based payment schemes and
referral audits
•Augmentation of AYUSH services.
• Rational utilization of RKS fund for patient
care.
•Strengthening
of ASHA programme
through Resource Centre, mentoring
group and telephone helpline
•Training in basic financial management to
doctors
as
part
of
professional
development course
•Develop a long-term master plan for
capital investments in districts
• Encourage involvement of NGO support
90
BIHAR
THE REVIEW TEAM:
1.
2.
3.
4.
5.
6.
Dr P K Srivastava, Joint Director, NVBDCP, GOI.
Dr. Jagvir Singh, Joint Director, IDSP, NICD, New Delhi
Dr.T.Sundararaman, Executive Director, NHSRC, New Delhi
Sh.Billy Stewart DFID India, British High Commission,
Prof. Rajesh Kumar PGI Chandigarh Professor & Head, Comm. Med. PGI, Chandigarh
G.N.V Ramanna, World Bank, New Delhi
THE DISTRICTS/ INSTITUTIONS VISITED:
District Muzaffarpur Sadar Hospital, Referral Hospital, Saraiya PHC: Bochaha, Saraiya, Paru,
Marwan APHC: Kuffin, Karza, Dawoodpur HSC - Pokharaira. Phulwariya, Kala Azar Medical
Research , DHS office and data center, ANM Training School, Nutrition rehabilitation Centre ,
ASHA training camp, AWC of Karza village
Vaishali District: Lalganj Sadar Hospital: PHC: Vaishali, MSF run hospital, Central District Drug
Ware House
Gaya DistrictLady Elgin Zanana Hospital,District health society office, Pilgrim Hospital, ANMTC
Magadh Medical College PHC, Belaganj. Khijarsarai.APHC, Kudwan., Bodh Gaya.JISC Mohanpur.
Progress under NRHM
Areas for improvement
• Increased utilization of most
• Addl. PHC strengthening for institutional deliveries; provision
services - outpatients, in patients,
of referral transport; Enhancing use of Untied Fund
institutional delivery at block PHCs • Filling of Regular vacant posts particularly nursing &
and district hospitals with over
specialists; HR policy, improvement of service conditions,
100% bed occupancy
skill upgradation
• Efforts to improve amenities &
• Higher allocation for drugs and management structure for
infrastructure; outsourcing
procurement; supply chain including contraceptives to be
arrangements for X ray &
improved.
cleanliness.
• Rationalization of public and private lab services at BPHCs
• Improved supply of drugs,
by workload; quality protocols in Labs
establishing generic medical stores •Vector control and programme management; Timely supplies
at Block PHCs.
• New treatment protocols for KA should be disseminated
• Increased human resources in
• Child health interventions to be prioritised
SCs, PHCs, DHs; innovative HR
•Supervisory mechanisms from district level for outsourced
policy, additional ANM at SC.
activities
• Nutrition rehabilitation
• Enhancing the range of beneficiaries exempted from user fee
programmes, Muskan ekAbhiyan
• Bridge courses to upgrade ASHA to AWW to ANM to
immunization program
Graduate Nurse and to Postgraduate Nurse to be set up
•Availability of Kala-azar kits
• Public Health Cadre to be create
• District health society meetings
•Quick disbursal of incentives to ASHA
held and well recorded, RKS in
• NGOs need to be monitored for outputs or quality
place.
•
Formation of VHSCs
•Societies of disease control
•Active
involvement of RKS members in funds utilization &
programs have been merged with
facility
development;
involvement of DHS in planning process
the health society,
•Functional coordination between the State Health Society,
•State initiated data centres and
Directorate of Health and program divisions
NRHM HMIS system both in place
91
CHHATISGARH
THE REVIEW TEAM:
1.
2.
3.
4.
Dr. R S Sharma,Joint Director, NVBDCP, Govt of India.
Dr Kaushik Ray Barman,Senior Consultant - Public Health Planning, NHSRC, New Delhi
Dr. Pavitra Mohan, Health Specialist, UNICEF India Country Office, New Delhi.
Dr. Joe Varghese, Senior Programme Coordinator, Christian Medical Association of India,
New Delhi
THE DISTRICTS/ INSTITUTIONS VISITED:
District Bilaspur: Sanatorium and Eye hospital (CHC Gourella), District Hospital, bilaspur CHC: Kota,
Pendra PHC: Ganiyari, Kenonchi, Amadand, Andhiarpur, Seepat SC: Gobripat, Kenwachi, Dahibahra,
Bacharwar, AYUSH Dispensary Pendra
Regional FW Training Center-Bilaspur.DPMU, Keonchi,
AWC, Jan Swasthya Sahyog Kendra, Ganiyari
District Dhamteri: Dist Hospital, CHC: Kurud, Nagri PHC: Bhakhara (Kurud),Megha (Magarload), Bade
Kareli (Magarload) Dugali (Nagri), SC: Bhakhara, Koliari, ANMTC
District Raipur: Directorate of H & F W ,SIHFW ,SPMU Medical college CHC, Abhanpur
Progress under NRHM
Areas for improvement
• Increasing trend of OPD, normal delivery at
CHCs and SCs, decline of malaria cases,
infrastructural and service improvement at
SCs are seen
• Exceptional teamwork between ANM,
Mitanin and AWW
• Innovative Initiatives: Recruitment of LT
through JDS (RKS), Rural Medical
Assistants initiative in tribal districts,
Centralised drug procurement system,
equipment management program,
partnership with Red Cross drug stores,
Telephone facilities for SC,
•Strong workforce of 60,000 Mitanin high
degree of skills, Mitanin help desks,
•Sishu sanrakhan mah, VHND, Swasth
Panchayat Scheme, Block Leprosy
Awareness Campaign
•92% VHSC are formed and account opened
for most of the VHSC
•Bal Hriday Suraksha Yojana started with
PPP mode
• Representation of other dept in SHS & DHS
• Sickle Cell test camps for screening have
been launched in the state
• Usage of bednets in indoor of facilities
•SPMU, DPMU working enthusiastically in
tandem with directorate and district officials
• More focus for PHCs, 24x7 services & SNCU
operationalisation ; Emergency drugs availability, MMU
for outreach activities should be streamlined ; SC & PHC
level facility survey, infrastructure upgradation
• Replenishment of supplies for Mitanin dawa Peti,
•sensitisation of PRI leaders in JDS activities , merger of
subaccounts, state budgetary contribution to SHS
account, operationalising E banking from dist to block
should be done on priority basis
• Institutional strengthening infrastructure development
wing, proper procurement policy, condemnation
procedure, training instt, HR policy, Public health
capacities in all personnel, More co-location with AYUSH
• Develop cohesion and rational distribution of work among
State health mission, SHRC, SIHFW & other training
institutions, & directorates
•streamline JSY based incentive distribution are to be
planned
•Timely Fund disbursements from state to districts, DHAP
based financial disbursement adopting ROP process for
districts
• Merger of sub accounts under SHS, transfer of state
contribution to NRHM pool, decentralization of financial
power need to be expedited
•Strengthening and sensitization of VHSC & PRI leaders,
Village level planning process, social auditing, community
monitoring need to be considered
• Frequent reshuffling of administrative and technical
officials to be reviewed
92
JHARKHAND
THE REVIEW TEAM:
1. Shri Amarjeet Sinha, (JS), MOHFW, GOI New Delhi
2. Dr.Dinesh Baswal (AC) Training, MOHFW, New Delhi
3. Dr. G. K. Ingle, Prof, Maulana Azad Medical College, New Delhi
4. Dr. Manoj Kar, Advisor, NHSRC, New Delhi
5. Dr.J.N.Sahay, Advisor, NHSRC, New Delhi
6. Dr. Nupur Basu, Member, National AMG, Delhi
THE DISTRICTS/INSTITUTIONS VISITED:
Hazaribagh District: District Hospital, PHC: Chouparan Barakatha Ichak Addl. PHC Basaria
HSC Chaikela, Thuthi .Kalabad , Silvar, Mahesra, ANM Training Centre, AYUSH Centre, AWC
Chaikela, HFWTC Hazaribagh
Mobile Medical Unit, Chanda,Community Monitoring, Sadan Sahiyyas
District West Singhbhum, Sraikela: SDH, Chkradharpur, Sadar hospital (Saraikela), PHC: Sonua,
Tantnagar, Zikpani APHC: Keraikela, Hatgamaria, SC: Kokcho, Singhpokharia, ghaghari,
Narsanda, Lupungutu, Others: AUYSH Disp Chaibasa, ANMTC, AWC jodapokhar
Progress under NRHM
Areas for improvement
• Increase in caseload at some Block PHCs and
sub-centres
• Doctors on contract at PHCs and Addl. PHCs.
• Infrastructure up-gradation initiated.
• Essential drug list and standard treatment
protocols prepared
• Sahiyas (ASHAs) are functioning well
• Community monitoring with NGOs has been
piloted in 15 villages
• RNTCP and NVBDCP shows an increase in
number of patients where as decrease in
number of leprosy cases
• Strong NGO support for Sahiyas & Community
processes
• MMUs serving unreached population.
• Focus on facility strengthening; Nonfunctional PHCs to be revived
• Improvement of drug supply, enhancing
OPD services
• Hospital quality management needs to be
strengthened
• JSY guideline still not clear to the health
providers
• Compensation package for Sahiya needs to
be improved; replenishment of drug kit
• Deployment of District Sahiya Facilitators
• Emphasis should be given to preparation of
District Health Action Plan involving multiple
stakeholder
• HR Policy necessary
• Nurses shortage to be met with setting up of
Nursing and ANM schools
• Residential accommodation for staff at
facilities
• HMIS to be strengthened
93
KERALA
THE REVIEW TEAM:
1.
2.
3.
4.
5.
Mr. Amardeep Singh Bhatia, Director, Nirman Bhawan, New Delhi
Dr. Ratan Chand, CD (Stat),Nirman Bhawan, New Delhi
Dr. K. S. Jacob, MSG,HoD,Psychiatry,CMC .Vellore
Dr. Narendra Gupta, AGCA, Secretary-PRAYAS, Rajasthan
Mr. Sunil Nandraj, WHO, New Delhi
THE DISTRICTS/ INSTITUTIONS VISITED:
District Thiruvananthapuram: Women and Children’s Hospital, Thycaud, Fort Hospital
CHC: Vizhinjum, Kesavapuram, Kanyakulangara PHC: Kunnathukal, Kuttichal, Pulluvalla SC:
Pazahayakunnume, Aramanoor, Karali, Muttukadu
Others: Directorate of Health Services, Kerala Medical Services Corporation Limited, Kerala State
Institute of Health Training Centre Tribal Health Camps, Pancode
Progress under NRHM
Areas for improvement
• Marked improvement in infrastructure and
human resources by the utilization of NRHM
funds.
• Increased availability and quality of
medication and marked reduction in cost of
drugs after the setting up of the Kerala Medical
Services Corporation Limited.
• The Compulsory Rural Service for doctors is a
major step forward.
• Initiation of the computerized HMIS.
• Successful setting up and use of the e banking
system.
• Good Outreach facilities. (WHND, Newsletter)
• A state-wide community based Pain and
Palliative Care program for terminal illness in
the community
• The initiation of comprehensive health
insurance scheme in collaboration with
Department of Labor.
• The selection process for ASHAs has been
good.
• There is wide variation in the performance
between districts, district/ taluk/ subdivision
hospitals, CHCs, PHCs, and Sub-centers. Need to
monitor the services from the point of input vs.
services and improve poorly performing regions.
Increase in the no. of field level functionaries in
underserved areas is urgently needed.
• There is a need to focus on Non-Communicable
Diseases
• A state wide emergency ambulance service needs
to be established.
• A disaggregated analysis of data from health
surveys can be used to identify disadvantages
groups (E.g. females, SC, ST, etc) for focused
action.
• Equipment bought should be audited for their
utilization and the value addition to services
• The NRHM coordinators seem not to be integrated
into the health system
• Maximising AYUSH facility utilization owing to its
strong presence (the State has more AYUSH
facilities than Modem medicine).
94
KARNATAKA
THE REVIEW TEAM:
1.
2.
3.
4.
5.
6.
Smt. Ganga Murthy, Economic Adviser, Ministry of Health & F.W.
Dr. V.R. Muralidharan, Prof, Humanities & Social Sciences, I IT Chennai
Shri A.K. Shiv Kumar, UNICEF, New Delhi
Dr. Dinesh Agarwal, UNFPA, New Delhi
Dr. Aditi Iyer, Research Consultant, I IM, Bangalore
Dr. Deoki Nandan, Director, NIH&FW, New Delhi
THE DISTRICTS/INSTITUTIONS VISITED:
Tumkur District: District Health & F.W. Office, District Hospital,titpur general hospital, PHC: Nittur,
Chelur, Biligere, Honnavalli, Kodigenahally Sub Centre:Somalapura,Thimmalapura„ ANM Training
Centre, Chikkamalur AWC, Goudi
Raichur District: Raichur,General Hospital, Dist. Health & F.W. Office., Sindhanur General Hospital,
Lingasugur, General Hospital, CHC: Kavithal.Mudgal, PHC: Matamari,Kallur,Kurdi,Hatti,Sirwar,Kalmala,
Sub Centre: Mallat Meganapur, ANM Training Centre, ASHA Trg. Centre, Drugs Logistics Centre
Progress under NRHM
Areas for improvement
• OPD, Institutional deliveries increasing in Sub
centers & PHCs
• Infrastructure created for facilities is impressive
• Significant initiatives for postnatal care,
investigation of maternal deaths, spacing methods
• Fixed monthly outreach plans at Sub-Centres.
• Medical doctors, paramedics and staff nurses
availability improved in public services,
• Public Health system at district level is under
purview of the Panchayat system
• District Health Action Plans created in all district;
meetings of DHS take place regularly .
• Well designed training program for ASHAs
• Concurrent audit in place in 6 districts,
• Web based HMIS introduced on pilot basis
• Community monitoring through VHSC piloted in 4
districts
• PHCs outsourced to NGOs, showing mixed results
• Good convergence with NACP III and ICDS in
VHND
• Suvarna Arogya Chaitnya School Health Program
• Holographic maternity card
• District Hospital, FRU to be strengthened
• New Born Care and Management of sick new
bom at peripheral facilities needs strengthening
• Coverage to be widened for EMOC and LSAS
trained MOs
• Quality Assurance needs focused attention
• Greater guidance and closer monitoring to
untied fund utilization
• AYUSH doctors role to be clearly defined and
oriented about NRHM
• Human Resources in health sector to be framed
• ANM training centres to e strengthened
• Quality of construction to be improved
• Conflict between ASHA/AWW/ANM for incentive
to be sorted-out
• Accounts for disease control program to be
merged
• E-transfer of funds to block level
• Capacity Building of Samiti members for
utilization of funds
95
MAHARASHTRA
THE REVIEW TEAM:
1.
2.
3.
4.
5.
Dr.A.C. Baishya (NE-RRC), Guwahati
Sh. Rajesh Kumar, FMG Nirman Bhawan, MOHFW, New Delhi
Sh.T.V.Antony, MSG Former Chief Secretary, GOI
Dr.K.B.Singh GTZ India,New Delhi
Ms. Sushma Rath, PAO. NHSRC, N Delhi
THE DISTRICTS/INSTITUTIONS VISITED:
District Pune, Raiqad-District hospital, Alibaug, Sub-dist H, Bhor, CHC: Manchar PHC:
Nagothane, Khedshivapur, Ambavade, Dimbe SC: Kikawi, Shinoli Others: Public Health
Laboratory, Zila Panchayat Pune, SHRC, State Transport Depot
District Nashik Thane-District Hospital Nashik, District Hospital Thane, Kalwan SubDist.
Hospital CHC: Rural Hospital ,Vani PHC: Karanjali, SC: Rasegaon, Ambegarh, Manur Others:
ANM/GNM training school, Regional FW Training Centre (Nashik)
Progress under NRHM
Areas for improvement
• improvement in OP load sub centers, PHCs and
CHCs and institutional deliveries.
JSY redressal Cell at district head quarters are
existing
• 30% of SC and PHCs upgraded to IPHS,
additional Blood storage facilities in them
• All 24x7 PHC with basic lab facilities, semi-auto
analyzer, ECG, and X-ray
• Well stocked with drugs and supplies with proper
storage conditions
• Free meals for mothers at institutions are
executed.
• Excellent involvement of PRIs, RKS and VHSCs
regularly participate in meetings and take part in PIP
preparation
• ASHAs well motivated and enjoy the confidence of
the community Support mechanism for ASHA in
place. VHSC formed and bank accounts opened.
• Untied fund for better health facilities is observed
• Two FMGs are created: one for NRHM, NPCB,
IDSP and the other for RCH, RNTCP, NLEP, and
NVBDCP.
• NGO based sickle cell disease control program,
MMUs providing services to underserved areas
• Sub district hospitals need to be improved for
better support for patients
• JSY incentive distribution need to be improved
• Newborn care at institute need to be
strengthened.
• Initiatives to be taken for more BPMUs to be
made functional
• Data is not made available on national website
under HMIS.
• Rational utilization of Civil works funds as per
guidelines
• Rationalization of posting of anesthetists
needed
• Maintain a Woman Friendly atmosphere at
institutional level
96
MIZORAM
THE REVIEW TEAM:
1. Shri Rajesh Bhatia, MoHFW, Govt. Of India;
2. Dr. Ashoke Roy, RRC NE, Guwahati
3. Dr.
rVijay^Aruldas,
.............
Christian
Medical^Association of India (CMAI), New Delhi;
4. Shri M. K. Talukdar, NHSRC, new Delhi
5. Dr.
r Sharad Iyengar, Action Research and Training for Health (ARTH), Udaipur.
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THE DISTRICTS/INSTITUTIONS VISITED:
District Kolasib: District Hospital,CHC: Vairengte PHC: Bilkhawthlir, Kanpui Lungdai SCBilkhawthlir,Diakkaun,Thingdawal,Bualpui,Zanlawn
District Serchhip: District Hospital CHC: Thenzawl PHC: Thingsuliah SC:
Chinchhip,Buangpui.Thenzawl
Progress under NRHM
Areas for improvements
• Presence of Regular MO has made
• Cash disbursement of untied fund, annual maintenance
positive impact on IPD / OPD at PHCs and
grant and non deposition of user fees in RKS
instt deliveries
• New bom care comer, Blood storage unit, functional OT
• Ssignificant number of home deliveries
at CHC, supply of RD kits & EC pills, emergency drugs to
being conducted by ANMs
be ensured
• Facility survey has been conducted in all
• Role differentiation among ASHA & ANM not well
the health institutions
understood by community hence need to be clarified
• ......
Well maintained facilities with ■proper
■
• Usage of HMIS data for feedback
and'atDTstr’ict'XNLi'18 (US'n9 RKS fUndS) ’nvbd"^ interSeCt°ral thrUSt should be develoPed with
and at District Hospital
• Central procurement of medicines,
• health workers of SC should be made aware of TB
Engineering cell for construction activities
patients as they are not DOTS provider
set up
• Ensuring home visits by health workers
• Upgradation of DH and CHC are already
• Need to invest in improve quality of primary healthcare
initiated
services beyond the clinical care by doctors
• ANM, Nurse, MPW (M) in fair numbers
• In service training for SN,
• Active involvement of the Village Council • Timely payment of JSY should be Initiated
Members In RKS
• Training in IMNCI & a maternal component might be
• District Health Society meetings not
considered as a pilot exercise
regular
• district mentoring groups, and district and block
• Financial recording at various facilities are facilitators for ASHA are suggested
in place
• Integrated compensation package for ASHA need to be
• VHSC are operational with a high degree
put in place
of involvement Pilot project on health
•
Involvement of SPMU & DPMU in JSY monitoring
insurance with Reliance,
suggested
• NGO participation In MMU are initiated
• More involvement of VHSC
• Training for DPM staff regarding District
•
oral health interventions might be considered by the
Action Plan formulation done
state.
• male health workers should be given an active role in
condom promotion and their performance need to be
monitored.
J
97
MADHYA PRADESH
THE REVIEW TEAM:
1.
2.
3.
4.
Shri Javed Chowdhury - Former Secy. FW, MOHFW, GOI
Dr. Kiran Ambwani -DC (FP) MOHFW, GOI
Dr. L. M. Nath -Former Director, AllMS, New Delhi
Dr. Manoj Kar -Advisor, NHSRC, NIHFW, New Delhi
THE DISTRICTS/INSTITUTIONS VISITED:
District Kaharqone: CMHO Office, Distt Hospital PHC:Padalia, Karhi, Pipalyabujurg, Bamnala,
Segaon, Unn SC: Dodwa, Bablai, Kavadiya, Lalkheda, Thibgaon, DPMU, District ICTC Services
Centre, AWC .Village gogariakhedi MMU - Mobile Medical Unit
District Dhar: CHC CEmOC, Sardarpur, PHC BEmOC PHC Nalchha, Amjhera, ANM Training
Centre, MMU at Sardarpur
Progress under NRHM
Areas for improvement
•Significant increase in IPD and instt delivery at SC,
PHC
• Newborn corners are in place in the labor rooms in
most of the FRUs
•Swastha Gram Swastha Panchayat- MCH services
being provided at CHC, PHC and Sub Health Centers
through specialists from Private Sector
• Janani Express vehicles for referral, Mobile health unit
(DINDAYAL CHALIT ASPATAL) in tribal blocks
• NABH Accreditation project in Bhopal & Jabalpur
initiated
•Sub-Center untied fund utilization has been high but
without the consent of Sarpanch
•ASHAs have a Identity card with drug kit, AYUSH
specific incentives for ASHA are planned
•VHSC formation under progress
•Outreach activities through Mobile Medical Units
• Insurance schemes for BPL families, Nutrition
Rehabilitation Centers , Janani Sahyogi Scheme
(Accreditation of Private Institutions) & Matra Shakti
Yojana through PPP for MCH services initiated
•Strong community monitoring pilot
• Infrastructure development a wing, Constitution of a
separate AYUSH cell, developed drug policy,
procurement through TNMC , Warehouses are initiated,
Privatisation of waste disposal,
•SPMU, DPMU, RKS are functional, Block PMU is
proposed, District Community Mobilisers recruitment in
Progress.
• Stregnthening of PHCs
• Quality assurance committee at various
health facilities to be formed
•Training of PMU staff and District
Programme Officers for District Health Action
Plan (DHAP)
•State funded construction should not be
replaced by NRHM funded constructions
• HR policy, upgradation of medical practice
skills of MO & SN are required, additional
incentives may be planned for persons
posted in difficult areas
•VHSC should be operational with formal
orientation
• Fund utilisation , PPP need to be
streamlined
•Timely availability of compensation,
replenishment of drug kits are critical and
need immediate attention
•State budget should flow into the Health
Society account
• HMIS needs improvement in reporting &
analysis
• MMUs should be made available on a more
frequent and regular basis.
•Additional incentives may be planned for
personnel posted in difficult areas
• Functional merger of Disease control
programmes with DHS, Nodal officer for M&E
is designated at the BEMOC and CEMOC
facilities need to be strengthened
• Development of District Health Action Plan
involving multiple stakeholders
• Monthly audit of district accounts
98
ORISSA
THE REVIEW TEAM:
1.
2.
3.
4.
5.
6.
Dr K.R. Antony, Director, SHRC, Chhattisgarh
Dr Prabha Arora, Deputy Director, NVBDCP, GOI
Dr. Ritu Priya, Advisor (Public Health Planning), NHSRC, New Delhi
Ms. Deepika Shrivastava, Specialist (Child Development & Nutrition), UNICEF
Dr Rajmohan Panda, Public Health Specialist, Public Health Foundation of India
Dr.H.Sudarshan AGCA, Hon Secretary, Bangalore
THE DISTRICTS/INSTITUTIONS VISITED:
District Dhenkanai Dhenkanal District Hospital, Kamakhyanagar SDH, CHC Anlibereni, Parajang ,
Sriramchandrapur PHC Guneibili, Khankira , Deogan, SC Mahulpal Sarang Parjang,
Sriramchandrapur, Sadangi
Village Gundrapasi, Badapokharia
District Subarnapur: Subarnapur DH.CHC: Tarva, Ullunda_PHC: Charbhatta, Naikenpal SC:
Kamsara , Charbhatta, Kotsamalai, Khaliapali, Kotsamalai AWC
Progress under NRHM
Areas for improvement
• Increased patient load and institutional deliveries
in CHCs, Sub-divisional & District Hospitals
• Effective use of untied fund at facilities
• ‘Yashodas’ in the hospitals as companions &
counselling women during delivery.
• PHC (N) and Mobile health units being managed
by AYUSH doctors
• NGO participation in NRHM activities for
management of Janani Express and a few PHC (N)
• VHSCs formed; PRIs, women’s SHGs and ICDS
actively involved with the health system.
• VHNDs being conducted as effective forums for
increasing community ownership and convergence
• Excellent GIS mapping for all districts
• NRHM financial guidelines are being followed very
effectively by the state
• The State and district IDSP operational.
• The State PMU has strong leadership and very
good working ethos. District PMUs are active,
professional and vibrant
• Bilateral donors such as NIPI and DFID providing
technical assistance in the State
•Strengthen PHC and Sub center services;
including staff quarters
•All vacancies for the NVBDCP from District
Malaria Officers to Lab. Technicians and MPW
(M) to be filled up.
•Integrated vector control, with engineering
works and use of biological control needs to be
strengthened; IT bednets supply to be
improved in high endemic zones
•An integrated Mother & Child Health, FRU
operationalisation, IMNCI roll out needs to be
given high priority.
• Linking of TBAs with ANMs for underserved
areas/ population groups.
• New born care equipments, Childhood illness
care at primary level needs strengthening;
•Scaling up of telemedicine facilities for “hard
to reach” areas.
•Transparency and need based procurement
and distribution of drugs, infrastructure
development mechanisms
• Creation of a public health cadre in the state
99
RAJASTHAN
THE REVIEW TEAM:
1. Dr. Gian Chand, Ex-Director Health Services, Government of Himachal Pradesh
2. Mr. Gautam Chakraborty, Senior Consultant, Financing of Health Care, National Health
Systems Resource Centre, New Delhi
3. Dr. Rajib Dasgupta - Associate Professor, Centre for Social Medicine & Community Health,
Jawaharlal Nehru University (JNU), New Delhi
4. Mr. Sanjay Saxena, Senior Advisor, Finance, Operations & Administration, NIPI-UNOPS, New
Delhi
5. Dr. Ute Schumann — European Commission, 16, Golf Links, New Delhi
THE DISTRICTS/INSTITUTIONS VISITED:
District- Jaipur, Dungarpur: SIHFW, Jaipur Medical College, Udaipur EMRI Centre- SIHFW
Campus, Jaipur, JK Lone Hospital Static Centre- Adarsh nagar, Janana Hospital CHC- Sagwada,
Simalwada, Bichhiwada, Govindgarh, Chomu, Bassi, PHC- Kaladera, Vatika, Tunga, Kanba,
Bhiluda, Dudhiabara Vidyadharnagar Urban RCH Centre Sub centre- Mohanpura, Bagrana,
Meghtalab, Bedsa, Narniya, Malikheda, Karauli VHSC Meeting- Vijaypura, Bedsa, Ramratanpura,
Meghtalab District ANM Training Centre- Dungarpur
Achievements
Areas of Improvement
• Marked increase in case load at all
levels.
• Human resource shortages minimised.
•All PHCs with MBBS doctors.
•ANMs under TSP contractual; drawing
hardship allowance under NRHM in
tribal/desert areas
•Approval of district PIP and release of
funds using flexi pool mechanism has
been initiated from 2008-2009. reducing
the no. of transactions and flexibility at the
district level.
• Pregnancy Tracking System (PTS)-individual record of identified pregnant
mother at Block level. Extending PTS to
PCTS (Pregnancy and Child Tracking
System
•Strengthening Community Health Centre services.
• District Health Missions, on the other hand, are nonexistent/non-functional.
•ANMs and doctors not residing in the facilities located in
difficult areas or located outside habitations.
•ANMs to be trained; were not confident of application of
Rapid diagnostic kits for malaria and haemoglobin
assessment available with them
•Clear guidelines for fixing of salary of DPMs and BPMs
• Institutional synergy between the Regional Institutes at
Jaipur and Ajmer, the Directorate, the SIHFW,
the
schools for LHV and ANM training.
•Need to streamline Social protection schemes that include
use of RMRS funds for the BPL, Rajasthan Swasthya Bima
Yojana, to BPL card holders& Bhamashah scheme!.
•Coordinated teamwork between the AWW, ASHA and
ANM
• Underweight / malnourished neonate identified by ASHAs
• Follow up of PNC visits and monitoring by ANM /
supervisor to be strengthened
• Design pneumonia control programme - with referral for
sepsis management.
•The register kept at the institution does not record
a)
Weight of the newborn b) condition at the time of discharge
- difficult to track pre mature / mal nourished neonate.
100
TAMILNADU
THE REVIEW TEAM:
1.
2.
3.
4.
5.
Prof A.T. Kannan Prof & Head of Department of Community Medicine, UCMS, New Delhi
Dr S. K. Sikdar Assistant Commissioner (Family Planning), Nirman Bhawan, GOI
Dr. D. Thamma Rao, Advisor - Public Health (HRD), NHSRC, New Delhi
Mr. Sushil Pal, Financial Management Group, Nirman Bhawan, New Delhi
Ms. Sheena Chabra, Chief, Health Systems Division , USAID, American Embassy New
Delhi
THE DISTRICTS/INSTITUTIONS VISITED:
Villupuram District
Kallaikurchi Hospital Kallaikurchi town
District Hq. Hospital
PHC: Saram.Kiliyanur ,lruvelpattu,Elavanasur Kottai,Nainarpalayam,Chinna .Thirunavallu SHC:
Kandhalavadi, Killapalayam .Sernpi
Salem District, Krishnaqiri, District, Vellore District
Progress under NRHM
Areas for improvement
• High par capita financial allocation, low out of • Promotion of nutritional improvement, early
diagnosis & treatment of Anaemia and health
pocket expenditure, good Infrastructure,
education of obesity in children, adolescents and
laboratory services, logistics situation are the
women,
male participation for Family Planning are
trend in Tamilnadu
required
• Facility survey, AYUSH collocation are in
• Strengthening of SC, remuneration for staffs of hilly
progress
areas,
• Fair number of instt is providing 24x7, FRU
facilities, diet for ANC cases, 2 nd day stay for • Reassess blanket JSY coverage, Streamline district
Post natal care, functional OT at PHC are
society meeting, provide rural and hard area
seen
allowance for all categories of health workers,
consider 2nd ANM , implementation of double ledger
• Maternity picnics, bangle & birth companion
accounting systems should be strengthened
programmes for pregnant women, Additional
• Reorientation trainings for ANMs to facilitate
SN in PHC, gestational DM screening &
decentralized preparation of Village and SHC level
preventive measures are observed
health action plans
• VHSC exists in town panchayats
• Skill up-gradation of laboratory Technicians and
• Filling up over 99% of specialist positions at
Radiographers
FRUs, rationalisation of posting & transfer
• Enhance intra-sectoral coordination (Directorates of
policy, promotional avenues, Relocation of
Public Health, Rural Health, Medical Education etc)
Specialists from periphery to bigger instt. Are
for strengthening of linkages
good initiatives.
• up-gradation of SDHs as per IPHS
• Smooth disbursement of Untied fund, Annual • Electronic transfer of funds to sub-district levels
Maintenance Grant, RKS fund in most of the
• Establishing Infrastructure Development division at
facilities
State level and units at district level for high quality
infrastructure
• Functional MMU with contractual staffs
• streamlining of the TNMSC procurement and
• ‘Short stay home’ for 10 days for the
distribution systems to eliminate short expiry drugs
expectant tribal mothers near the health
•
Capacity building of the six regional training
facilities is a good initiatives
institutes for Continued Medical/ Nursing/
• computer and internet connectivity in PHC
Paramedical Education
• Plan definite program for all non communicable
diseases
|» VHND need to be augmented__________
101
UTTARPRADESH
THE REVIEW TEAM:
1.
2.
3.
4.
5.
Dr. N. C. Saxena, Consultant, UNICEF India Country Office, UNICEF House, New Delhi
Dr. Sunil D. Khaparde Dy. Commissioner (Immu. & ID) MOHFW, New Delhi
Dr. Arun Kumar Sharma, Professor in Community Medicine, UCMS, New Delhi
Dr. P Padmanabhan, Advisor (Public Health Administration) NHSRC, New Delhi
Mr. Gopi Gopalakrishnan, President World Health Partners, New Delhi
THE DISTRICTS/INSTITUTIONS VISITED
District Unnao and Bharaich: District Hospital for Women & Men- Unnao, CHC-Nawabgunj,
Block PHC- Safipur, Fatehpur Chauras, Achalgunj, Asoha, Kalukhera, Hiloli, Addl. PHCRoop Pur Chandel, , SHC- Jamalpur, Kardhaha, Kalukhera Village- Dhannapur, Pichauda,
Sarai, Katha
Progress under NRHM
Areas of Improvement
• Upsurge in institutional deliveries and
increasing OPD attendance
• Excellent improvement in infrastructure
of facilities, Very spacious HSC
buildings.
•Those in position work hard to deliver
health care
•ANMs and ASHAs are well accepted
and respected in the community
• RKS formed up to Block PHC level
•Steps taken to activate VHSCs - 2nd
October
• Clear Guidelines for the use of funds
•Second ANM and MPW (M) needed at Sub-centres
•Active screening for communicable diseases
(Malaria) needs more attention
• FRU and Mobile medical Units not operationalised
• Mapping of human resource and redistribution for
rationalization of services at different levels following
IPH standards is recommended.
•Creation of a public health cadre
• Mass media campaigns to inform community about
facilities created and their benefits
•Transparent policy and procedures for recruitment
and transfer of workers, protection of erring workers.
• Funds for new PHCs
• PRIs not uniformly involved for VHSC
•Monitoring and supportive supervision of programs
should be ensured
•Rapid grievance redress for staff and beneficiaries.
•Community participation and social audit to be
encouraged
•Nutrition supplementation, nutrition rehabilitation
and provision of food for mothers after delivery and
after tubectomy
• HMIS and data utilization for planning and
monitoring
Expansion of nursing education and post graduation
in specializations where there are inadequate
specialists.
102
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