10183.pdf
Media
- extracted text
-
DRAFT
NRHM
o|
1
unftw ww IhtH’
BROAD FRAMEWORK FOR
PREPARATION OF DISTRICT
HEALTH ACTION PLANS
AUGUST 2006
A
National Rural Health Mission
Ministry of Health & Family Welfare
Government of India
1U133
Table of Contents
TOPICS
CHAPTERS
Executive Summary
PAGE
Nos.
3-10
11-13
Chapter 1
National Rural Health Mission
Chapter 2
District Health Action Plan: Broad Contours
Chapter 3
Resource Allocation and Financial Norms
36-40
Chapter 4
Conducting Situational Analysis
41-59
Chapter 5
Block Level Consultations (BLC)
Chapter 6
Setting Objectives of the DHAP
Chapter 7
District Planning Workshop
Chapter 8
Workplan and Unit/Average Costs
Chapter 9
Monitoring and Programme Management
85-91
Chapter 10
Structure of the District Health Action Plans (DHAP)
92-93
14-25
60-70
71-78
79-80
81-84
94-146
Annexures
Community Health Cell
Library and Information Centre
tt 359, “Srinivasa Nilaya"
Jakkasandra 1st Main,
1st Block, Koramangala,
BANGALORE - 560 034.
Ph :2553 15 18/2552 5372
e-mail: chc@sochara.org
2
Executive Summary
BACKGROUND:
The Hon'ble Prime Minister launched the NRHM on 12th April, 2005 throughout the country
with special focus on 18 States, including eight Empowered Action Group (EAG) States, the NorthEastern States, Jammu & Kashmir and Himachal Pradesh.
zThe NRHM seeks to provide accessible, affordable and quality health care to the rural
population, especially the vulnerable sections. It also seeks to reduce the Maternal Mortality Rate
(MMR) in the country from 407 to 100 per 1,00,000 live births, Infant Mortality Rate (IMR) from 60 to
30 per 1000 live births and the Total Fertility Rate (TFR) from 3.0 to 2.1 within the 7 year period of
the Mission.
IMPLEMENTATION FRAMEWORK & PLAN OF ACTION FOR NRHM
The key features in order to achieve the goals of the Mission include making the public health
delivery system fully functional and accountable to the community, human resources management,
community involvement, decentralization, rigorous monitoring & evaluation against standards,
convergence of health and related programmes from village level upwards, innovations and flexible
financing and also interventions for improving the health indicators.
The Diagrammatic Representation of the 5 Main approaches of NRHM is illustrated
below:
NRHM - 5 MAIN APPROACHES
COMMUNITIZE
/
/
/
X
MONITOR,
PROGRESS AGAINST
STANDARDS
1. Hospital Management
Committee/ PRIs at all levels
2. Untied grants to community/
PRI Bodies
3. Funds, functions &
i
functionaries to local
\
community organizations
\
4. Decentralized planning,
\
Village Health &
\
Sanitation
/
Committees
//
I
FLEXIBLE FINANCING
1. Untied grants to institutions
2. NGO sector for public
Health goals
3. NGOs as implementers
4. Risk Pooling - money
follows patient
\
5. More resources for
/
Xk
more reforms
IMPROVED
MANAGEMENT
THROUGH CAPACITY
1. Block & District Health
Office with management skills
2. NGOs in capacity building
3. NHSRC / SHSRC / DRG / BRG
\ 4. Continuous skill development /
\
support
/
1. Setting IPHS Standards
2. Facility Surveys
3. Independent Monitoring
Committees at
Block, District & State
.
levels
/
INNOVATION IN
HUMAN RESOURCE
MANAGEMENT
1. More Nurses - local
Resident criteria
2. 24 X 7 emergencies by
Nurses at PHC. AYUSH
3. 24 x 7 medical emergency
atCHC
4. Multi skilling
3
-.-I
1
IMPROVING THE PUBLIC HEALTH DELIVERY SYSTEM
Given the status of public health infrastructure in the country, particularly in the EAG and the
North Eastern States, it will not be possible to provide the desired services till the infrastructure is
sufficiently upgraded^. The Mission seeks to establish functional health facilities in the public domain
through revitalization of the existing infrastructure and fresh construction or renovation wherever
required. The Mission also seeks to improve service delivery by putting in place enabling systems at
all levels. This involves simultaneous corrections in manpower planning as well as infrastructure
strengthening. The Mission would provide priority to both these aspects.
A generic Public Health Delivery System envisioned under NRHM from the Village to
the Block Level is illustrated below:
NRHM-ILLUSTRATIVE STRUCTURE
Health Manager
Accountant
BLOCK LEVEL HEALTH OFFICE
Store Keeper
/BLOCK\
LEVEL \
HOSPITAL \
Ambulance
\
Telephone
Obstetric/Surgical Medical
Emergencies 24 X 7
Round the Clock Services;
100,000
Population
100 Villages
Accredit private
providers for public
health goals
30-40 Villages
Strengthen Ambulance/
transport Services
Increase availability of Nurses
Provide Telephones
Encourage fixed day clinics
CLUSTER OF GPs - PHC LEVEL
/
3 Staff Nurses; 1 LHV for 4-5 SHCs;
\
/Ambulance/hired vehicle; Fixed Day MCH/lmmunization\
/
Clinics; Telephone; MO i/c; Ayush Doctor;
\
Emergencies that can be handled by Nurses - 24 X 7;
Round the Clock Services; Drugs; TB / Malaria etc, tests
5-6 Villages
1000
Popu /
lation /
GRAM PANCHAYAT - SUB HEALTH CENTRE LEVEL
Skill up-gradation of educated RMPs / 2 ANMs, 1 male MPW FOR 5-6 Villages;
Telephone Link; MCH/lmmunization Days; Drugs; MCH Clinic
VILLAGE LEVEL - ASHA, AWW, VH & SC
1 ASHA, AWWs in every village; Village Health Day
Drug Kit, Referral chains
/
PUBLIC HEALTH INFRASTRUCTURE
The Central Govt, has so far supported only the construction/up gradation of sub-centres/
Because of their difficult financial conditions, the States have usually not provided sufficient funds for
construction / up-gradation of Primary Health Centre [PHC]/Community Health Centre [CHC]/District
Hospitals etc. As a result, health infrastructure is in poor condition in most of the states. NRHM
allows the expenditure for construction subject to the condition that it should not be more than 33%
of the total NRHM outlay in the case of high focus States, and, 25% in the case of non-high focus
States. NRHM also provides for up-gradation of District Hospitals.
In the first Cabinet approval, provision had been made forgetting up of Indian Public Health
Standards (IPHS) only for Community Health Centres (CHCs)/PHC$. The Mission now provides for
IPHS at all levels i.e., sub-centres PHC/CHC and district hospitals.
4
As per the original Cabinet approval, untied grants were to be made available only to sub
centres. However, the Mission now proposes provisions for untied funds at PHC/CHC/district levels.
A provision for funds for taking up innovative schemes at district/State/Central level has also been
made.
x Having Rogi Kalyan Samitis for managing health facilities has already been approved,.by the
Cabinet. Now funds would be released as corpus grants to these Samitis as 100% grant'by GOI
during 2006-07, while it would be in the ratio 2:2:6 with regard to State / Internal / GOI from 11th
Plan onwards.
The Mission also seeks to ensure the availability of requisite equipments and drugs at all the
public health care facilities. /Procurement of equipments/ drugs would be progressively decentralized
and a road map prepared.
/it is proposed to improve outreach activities in un-served and underserved areas specially
inhabited by vulnerable sections through provision of Mobile Medical Units [MMU] in every district
under this proposal. The MMUs would also cover Anganwadi centres.
IMPROVING AVAILABILITY OF CRITICAL MANPOWER
The issue of availability of critical manpower in the rural areas is proposed to be addressed
through initiatives like introduction of a trained voluntary community Health Worker (ASHA) in every
village of the 18 high focus states, additional ANM at each sub-centre, three staff nurses at the
Primary Health Centres (PHC) to make them operational round the clock and additional specialists
and paramedical staff at the Community Health Centres (CHC). The condition of local residency is
proposed to ensure that the staffs stay at their place of posting. In the North-east, keeping in view
the difficulty in availing services of doctors and specialists, the emphasis is op recruitment, training
and skill upgradation of locally recruited ANMs/nurses/midwives/ para medics/ It is also proposed to
^Supplement the availability of critical manpower across the States through contractual
appointment/local level engagement of medical and paramedical manpower upgrading and multi
skilling of the existing medical personnel.
Innovations in Public private participation for service
provision, franchising of service providers, licensing and training of Rural Medical Practitioners
(RMP), rationalization of existing manpower are few of the innovations/options being explored.
Stringent monitoring at all levels, involvement of the PRIs and monitoring by the Rogi Kalyan Samitis
should ensure presence of doctors & para medicals in the rural areas. Besides compulsory posting of
doctors in the rural areas, better cadre management & personnel policies would also help to improve
manpower availability..
CAPACITY BUILDING
In order to provide managerial support, for tracking funds and monitoring activities under the
Mission, provision has been made for setting up Programme Management Units at the State/District
level. Over 500 professionals have already been recruited. The successful implementation of the
Mission would require health sector reforms and development of human resources. Capacity building
at all levels is a huge challenge under NRHM. In order to provide technical support to the Mission for
achieving this objective, it is proposed tp set up National Health System Resource Centre [NHSRC] at
the Central and State levels (SHSRC) with an annual corpus support of Rs. 15 crore and Rs. one
Crore at the Central and State levels respectively. The NRHM also emphasizes the setting up of fully
functional Block and District level Health Management systems, as under NRHM 70% of the
resources would be utilized at Block and below Block levels and 20% at the district lev§K Given the
large army of ASHAs, ANMs, Nurses and Rural Medical Practitioners continuous skill development is
5
needed' Strengthening nursing institutions, linking medical colleges for providing skill development
support to rural health workers, involving the voluntary sector in skill development are few key
interventions to be taken up.
/ To make the health facilities more accountable, their control would be gradually shifted to the
PRIs and civil society. The Sub-centres are proposed to be placed exclusively under the control of the
Panchayat. The PHCs and CHCs are also to be managed by the Panchayat Block Samitis (PBS) and
Rogi Kalyan Samitis (RKS).
COMMUNITY HEALTH WORKERS
As per the approval of the Cabinet dated 4.1.2005xdne female Accredited Social Health
Activist (ASHA) is to be provided for every village with ^population of 1000 (with provision for
relaxation in the eight EAG States, Jammu and Kashmir and Assam) in each of the high focus states.
She would be the link between ttre community and the health facility and would be the first port of call
for any health related demand; Now under the Mission, it is proposed to have an ASHA in all the 18
high focus States. BesidesZ'based on the recommendations of the Committee of Secretaries (COS)
in its meeting held on 20.10.2005, it is also proposed to support ASHAs in tribal districts of all the
remaining States. In case the other States would like to extend the scheme in remaining districts as
well, it would be possible forthem to do so under the RCH II. ASHA along with Anganwadi workers
(AWW) & the Auxiliary Nurse Midwife (ANM), Self Help Groups & community based organizations,
preraks of continuing education centres through their coordinated action at the village level & through
combined organization of monthly Village Health, Nutrition & Sanitation day at the Anganwadi centres
would be expected to bring about perceptible changes in the health status of the community^
/ CONVERGENT ACTION ON OTHER DETERMINANTS OF HEALTH
The PRIs and a large range of community based organizations like Self Help Groups, School,
water, health Nutrition & Sanitation Committees, Mahila Samakhya Groups, Zila Saksharta Samitis
provide an opportunity for seeking local levels accountability in the delivery of social sector
programmes. Schools and Anganwadis would form the base of these activities. NRHM provides for
School Health Check-ups and School Health Education to be worked out in c/nsuRation with the
States. Convergence of programmes would be at the village and facility levels.
/DECENTRALIZATION
As the indicators of health depend as much on drinking water, nutrition, sanitation, female
literacy, women’s empowerment as they do on functional health facilities, NRHM seeks to adopt a
convergent approach for interventions under the umbrella of the district plan which seeks to integrate
all the related initiatives at the village, block and district levels. The District Health Action Plan
would be the main instrument for planning, Inter-sectoral convergence, implementation and
monitoring of the activities under the Mission^ Rather than funds being allocated to the states for
implementing programmes designed and approved at the GOI level, the States would be encouraged
to prepare their perspective and annual plan which in turn would be based on the District Plans. Even
though village is envisaged as the primary unit for planning, looking at the extensive capacity building
required before it would be in a position to take up the exercise, the Mission would not insist on the
village plans at least during the first two year^zThe District Health Mission under the Zilla Parishad
would get the district plan prepared covering health as well as the other determinants of health.
Household and Facility Surveys would define the baseline. Periodic surveys would thereafter be
taken up on an annual basis to track the improvements in the facilities as well as in the reduction in
health indicators. The District Plans would be collated into a State Plan which would be appraised
and approved by the Mission at the national level. As far as the other determinants of health are
6
concerned, the funds for them would continue to flow through the existing channels but the District
Plan would clearly bring out the convergent action being taken at the district level.< NRHM recognizes
that delegation of financial and administrative powers/at various levels would be necessary for the
successful implementation of the decentralized plans. A Framework for delegation of powers is given
in Annex- VII
MAINSTREAMING OF AYUSH
Provision has been made for State specific proposals for mainstreaming AYUSH, including
appointment of AYUSH doctors/paramedics on contractual basis, providing AYUSH Wings in PHCs
and CHCs. As envisaged under NRHM vision and goalsfefforts will be made to integrate AYUSH in
primary health delivery.
FLEXIBLE FINANCING
The programmes under the erstwhile Departments of Health and Family Welfare and
Department of AYUSH were not being run in an integrated manner. As a result the transfer of funds
to the states under different budget heads at different points of time vertically hampered flexibility. It
also led to duplication of efforts, and, thereby, wastage of scarce resources. For improved delivery,
the Mission attempts to bring the schemes of the Ministry of Health & Family Welfare within the
overarching umbrella of NRHM as approved earlier by the Cabinet. Therefore^" under the
Implementation Framework, from the Eleventh Plan onwards, it is proposed to have a single budget
head for the activities under the Mission. This would provide the States much needed flexibility to
direct the funds to those areas where they are needed the most. However, a minimum amount would
be earmarked for various disease control programmes to ensure that the national objectives and
commitments are meV-The funds under the NRHM budget head would flow through the integrated
health society at the State and the District levels. The norms under which the funds would be
allocated by the Centre to the States and by the States to districts on the basis of Integrated
State/District Health Activity Plans have been clearly spelt out in the Implementation Framework.
NORMATIVE FRAMEWORK
I
The District Health Action Plans would be prepared based on a normative framework. The
cost norms have been derived from three sources. First, existing norms of the schemes brought
under the umbrella of the NRHM. Secondly, norms developed by the NCMH. Thirdly, norms
developed and approved as new interventions under NRHM.
MONITORING AND ACCOUNTABILITY FRAMEWORK
The NRHM Framework is based on a rights based approach. The Framework proposes
accountability at every level through a three pronged process of community based monitoring,
external surveys (SRS, DLHS household surveys by ASHA, facility surveys in the district level) and
stringent internal monitoring. The process of community involvement of the health institutions itself
would enhance accountability and the NRHM would facilitate this process by wide dissemination of
the results.,. For effective monitoring a strong MIS is being put in placeX The Citizen Charter would
/help the public to know their rights and entitlements at each facility. The setting up of IPHS at each
level of health delivery system would be instrumental in provision of minimum service guarantees at
those levels. Monitoring also would be in terms of service guarantees provided by each facility,
utilization of such services by the community {especially weaker sections} changes in their health
seeking behavior, etc. The Facilities Survey is expected to create a baseline for each health facility
and assist in monitoring annual progress against the baseline in terms of services guaranteed./The
7
MOUs signed with the States would enable monitoring of progress under NRHM in terms of the
agreed milestones^ Independent evaluation would ensure midcourse corrections.
PRO-PEOPLE PARTNERSHIPS WITH THE VOLUNTARY SECTOR
Investments by voluntary Organizations are critical for the success of NRHM. The Mission
provides for partnerships with the voluntary groups/ organisations for advocacy, building capacity at
all levels, monitoring and evaluation of the health sector, delivery of health services and working
together with community organization^/ It is proposed to provide people friendly regulatory
framework that promotes ethical practice through accreditation, standard treatment protocols and
training and, upgradation of skills of non-government health providers. 5% of the total NRHM outlay is
proposed to be the resource allocation to voluntary organizations on the basis of approved guidelines
& norms.
REDUCING IMR/MMR/TFR AND THE DISEASE BURDEN
Reproductive and Child Health Programme (RCH-II) was launched in 2005 as a part of the
Mission as the principal vehicle for reducing IMR, MMR and TFR as envisaged in the original Cabinet
Note. Upgradation of Community Health Centres as First Referral Units (FRUs) for dealing with
Emergency Obstetric Care, 24x7 delivery services at the PHCs, operationalising of Sub-Centres
multi-skilling of doctors, contractual appointments of MOs and AMOs, training medical officers in
Anesthetic skills, training doctors/ANMs/Nurses as Skilled Birth Attendants (SBA) permitting ANMs
to administer certain drugs in emergency, partnerships with voluntary organizations, RCH camps
accreditation of non profit organizations, IEC activities are the major interventions in reducing MMR.
For reducing neo natal mortality programme for Integrated Management of Childhood illnesses
(IMNCI) is being extended at the community and facility levels. Activities of ASHAs, Anganwadi
workers and ANMs, preraks of continuing Education Centres and SHG groups at the village level with
focus on both preventive and promotional aspects of health care accelerated immunization
programme, advocacy on age of marriage/ against sex selection, spacing of births, institutional
delivery, breast feeding, meeting unmet demands for contraception, besides providing a range of
RCH services are to have impact on reducing the health indicators.
Efforts are being made to
integrate HIV AIDS programme with the RCH at the district and sub-district levels. Convergence of
disease control programmes, integration of services, combined awareness generation, education and
the advocacy at community and facility levels, taking care of preventive, promotive and curative
health care-are expected to bring down IMR/MMR/TFR and the disease burden as stated in the
proposal.
RISK POOLING AND THE POOR
The Mission recognizes thatXn order to reduce the out of pocket expenditure of the rural^poor,/
there is an imperative need for setting up effective risk pooling systems as already envisaged. State
specific, community oriented innovative and flexible insurance policies need to be developed and
dissemi’nated/While the first priority of the Mission is to put the enabling public health infrastructure
in place, varrous innovative models would be pilot tested to assess their utility.
FINANCING OF NRHM
The National Commission on Macroeconomics and Health (NCMH) has worked out an
additional requirement of non recurring expenditure of Rs. 33811/- crores per annum and additional
recurring expenses of Rs. 41006 crores at current prices for delivering functional health care in the
public domain. This outlay, which would be shared by the Centre and the States, would push the
expenditure on Public Health care to nearly 3% of GDP. As some of the elements included in this
8
computation of fund requirement relate to activities which are not strictly covered under the NRHM
(like setting up of medical colleges etc) and if allocations to be made on such activities are excluded,
then the additional capital and recurring requirements come to Rs. 30,000 crores and Rs. 36,000
crores per annum respectively over and above the current allocations. It may, however, be mentioned
that with growth in GDP, in order to maintain the same percentage level of health expenditure vis-avis GDP, the expenditure would have to go up in the same proportion.
Given the absorptive capacities of the States and the time it may take up to build their
capacities, it is projected in the implementation framework that there would be a 30 % annual
increase in the central allocation for health till 2007-08, which, thereafter is envisaged to grow at the
rate of 40 %. If the projected funds become available, the public health expenditure is likely to reach
2% of the GDP from the current level of 0.9%.
In order to step up the expenditure on public health over the next 5 years, the states also have
to very significantly increase the allocation for the health sector in their budgets, since they contribute
almost 4/5th of the current total expenditure. The EFC has agreed that under the NRHM, 100 % grant
be provided to the states during the 10th'Plan which could be phased downwards to 85% in the 11th
and 75% in the 12th Plan.
TIME LINES
Clear time lines have been worked out for NRHM activities as also for system of outcome monitoring that
may be seen at Annex-VI.
v
ABOUT THE DISTRICT HEALTH MANUAL
This Manual is intended to be a user-friendly tool to assist range of stakeholders, to be engaged in
the district health planning/in developing the DHAP. The intended target group for this document
includes:
□ Members of State and District Health Missions
□ District & Block level programme managers of line departments i.e., Health and Family
Welfare, AYUSH, Women and Child Development including ICDSs and water/sanitation.
□ State Programme Management Unit and District Programme Management Unit Staff
□ Members of PRIs and MNGOs/ FNGOs and civil society groups (in case these groups are
involved in the DHAP formulation)
Besides above referred groups, this documenJ/Will also be found useful by public health
managers, academicians, faculty from training institutes and people engaged in programme
implementation and monitoring and evaluation.
This Manual needs to be used in conjunction with many other documents. It is highly
recommended that the planning team entrusted with the task of developing the plan have access to
all the documents listed in the annexure as ahead of the commencement of planning process and
familiarize themselves with the contents of these documents.
9
STRUCTURE OF THE DISTRICT HEALTH MANUAL
Information in this Manual is organized in 10 chapters along with an executive summary. Chapter 1
&2 provide the overarching NRHM context in which DHAPs are embedded and the Broad Contours of
the District Planning Process.
Chapter 3 guides a reader on the financial resources, funding sources and guidelines for allocation of
resources available for the programming purposes, on an annual basis. This section will guide the
planning teams on the probable allocations they could make for the State level interventions and the
funds that are to be programmed at the District level.
Chapter 4 provides insights for organizing activities during a preparatory phase ahead of actual plan
formulation. A comprehensive situational analysis with the help of primary and secondary data
sources is critical to sound planning. The planning team at district and block-level should access
different data sources for district and analyse them with the help using the suggested templates.
Chapter 5 refers to the processes and activities that need to be undertaken at block level and district
level. Block consultations are the first step towards engaging community in developing plans in a
meaningful and participatory manner. Much will depend on how block level consultations are
facilitated and skill the facilitators possess. Also these consultations will act as trendsetters for the
ultimate village health planning as reflected in the NRHM implementation framework.
Chapter 6&7 explains in detail about how to set the plan objectives in light of situation analysis,
problems diagnosis and needs assessment. As NRHM focuses on achieving outcomes, a results
focus has to be reiterated. District planning team is guided through use of templates as how to set
objectives or conducting a force field analysis
for arriving at the outputs/programme results to
be achieved. A programme LFA will also help in developing a results chain. Activities to achieve
higher-level results should be considered after taking into cognizance solutions offered in the block
level
consultations.
Chapter 8 & 9 deals with development of work plans, budgets, Monitoring & Evaluation plan including
Programme Management.
Chapter 10 gives a Structure of the District Health Plan
10
1
National Rural Health Mission (NRHM)
The National Rural Health Mission (NRHM) aims to provide for an accessible,
affordable/acceptable and accountable health care through a functional public health
system..
It is designed to galvanize the various components of primary health system, like
preventive, promotive and curative care, human resource management, diagnostic
services, logistics management, disease management and surveillance, and data
management systems etc. for improved service delivery. /
Q
This is envisioned to be achieve/by putting in place an enabling institutional
mechanism at various levels, community participation, decentralized planning, building
capacities and linking health with its wider determinants. It also aims to expedite
achievements of policy goals by facilitating enhanced access and utilization of quality
health services, with an emphasis on addressing equity and gender dimension.
Vision
'
To provide effective healthcare to rural population throughout the country with
special focus on 18 states, which have weak public health indicators and/or weak
infrastructure.
To increase public spending on health from 0.9% GDP to 2-3% of GDPyVvith
improved arrangement for community financing and risk pooling/
To undertake architectural correction of the health system to enable it to
effectively handle increased allocations and promote policies th/strengthen
public health management and service delivery in the country^7
To revitalize local health traditions and mainstream AYUSH into the public health
system.
Effective integration of health concerns throughz decentralized management at
district, with determinants of health like sanitation and hygiene, nutrition, safe
drinking water, gender and social concerns.
Addresses inter State and inter district disparities.
Time bound goals and report publicly on progress.
To improve access to rural people, especially poor women and children to
equitable, affordable, accountable and effective primary health care.s
11
b
Objectives of NRHM
□ Reduction in child and maternal mortality
Universal access to public services for food and nutritign, sanitation and hygiene
and universal access to public health care service^/With .emphasis on services
addressing women’s and children’s health and universal immunizatiqiy
□ Prevention and control of communicable and non-communicable diseases,
including locally endemic diseases.
□ Access to integrate comprehensive primary health care.
□/Population stabilization, gender and demographic balanq/
□ Revitalize local health traditions & mainstream AYUSH.
□ Promotion of healthy life styles/
Approaches of NRHM
'□ Communitize: this will entail transfer of funds, functions and functionaries to PRIs
and also greater engagement of RKS, Hospital development committees or user
groups etc
,
Improved
management
through
capacity:
Right
from
the
national
level,
NRHM
□
visualizes a sustained process of capacity development of management of the
programme through, NHSRC, SHRCs. Besides these institutional arrangements
district and block level health management systems are being suggested, so that
programme is more, responsive to local management needs and challenges
□ Flexible financing: Programme aims for making available untied funds at different
levels of health care delivery system so that service guarantees as spelled out in
the IPHS can be made available
□
□ Monitor progress.against standards: Facility surveys will setup the benchmarks
for the purpose of monitoring achievements of standards. Also additionally
preparation of the annual reports by independent agencies will help in publishing
z
these reports.
□ Innovation in human resource management One of the major challenge in
making health services effectively avaijable to the rural poor involves innovations
in human resources management/RHM proposes, ensuring availability of
locally resident health workers, contractual positions, multi-skilling, integration
with AYUSH etc so as to optimally use human resources
Core Strategies of the Mission
□ Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own, control
□
□
_^a
□
and manage public health service^7
Promote access to improved healthcare at household level through the female
health activist (ASHA). '
/
Health Plan for each‘Village through Village Health Committee of the Panchayat.
Strengthening sub-centrS through better human resource development, clear
quality standards, better Community support and an untied fund to enable local
planning and action and^fnore Multi Purpose Workers (MPWs).
Strengthening existing (PHCs) through better staffing and human resource
development policy, clear quality standards, better community support and an
untied fund to enable the local management committee to achieve these
standards.
12
z-
Za
Provision of 30-50 bedded CHC per lakh population for improved curative care to
a normative standard. (IPHS defining personnel, equipment and management
standards, its decentralized administration by a hospital management committee
and the provision of adequate funds and powers to enable these committees to
reach desired levels)
Preparation and implementation of an inter sector District Health Plan prepared
by theZ)istrict Health Mission, including drinking water, sanitation, hygiene and
nutrition.
Integrating vertical Health and Family Welfare programme^t National, State,
District and Block levels.
Technical support to National, State and District Health Mission, for public health
management
Strengthening capacities for data collection, assessment and review for evidence
based planning, monitoring and supervision.
Formulation of transparent policies for deployment and career development of
human resource for health/
Developing capacities for preventive health care at all levels for promoting
healthy life style, reduction in consumption of tobacco and alcohol, etc.
Promoting non-profit sector particularly in underserved areas.
Role of the District Health Mission
Responsible for planning, implementing, monitoring and evaluating progress of
Mission.
Preparation of Annual and Perspective Plans for the district.
Suggesting district specific interventions.
Carrying out survey of non-governmental providers to see what contribution they
can make.
Partnerships with NGOs, Panchayats for effective action.
Strengthening training institutions for ANMs/Nurses, etc.
Provide leadership to village, Gram Panchayat, Cluster & Block level teams.
Establish Resource Group for Professionals also can facilitate implementation of
core strategies of the Mission.
Experiment with risk pooling for hospitalization.
Ensure referral chain and timely disbursement of all claims.
Arrange for technical support to the blocks teams and for itself.
Arrange for epidemiological studies and operational research to guide district
level planning.
Nurture community processes.
Transparent systems of procurement and accountability.
Activate women’s groups, adolescent girls’ fora to ensure gender sensitive
approach
Provide _data analysis and compilation facility in order to meet regular MIS
needs.
Carry out Health Facility Surveys and supervision of household surveys.
District Health Mission to ensure that district annual action plan as per RNTCP
requirement would continue to be submitted by the district to the state TB cell..
13
Cheptr
2
DISTRICT HEALTH ACTION PLAN
Broad Contours
In order to make NRHM fully accountable the District Health Plan will be the
principle instrument for planning, implementation and monitoring. , formulated through a
participatory and bottom up planning process. District Health Mission has been
constituted in the districts as per guidelines.
As a next step each district has to formulate/design District Health Action Plan
(DHAP). To facilitate this process, a DHAP manual is being put together. The DHAP will
contain situational analysis of the district, objectives and intervention^, work plan and
budgets and an M&E plan.
The DHAP document will be appraised and approved at State level and will be
guiding document for implementation, monitoring & evaluation of NRHM activities in the
district. It is envisaged that decentralized programme management is likely to be more
responsive to the health care needs of local community and will be a step towards
ultimate communitisation - a hallmark of NRHM.
The District Health Mission has been entrusted with the responsibility of steering
formulation and ensuring implementation of the plans. In preparations for development
for the DHAPs, the Health Mission may constitute a Planning Team in which they may
like to co-opt other members such as MNGOs to be part of the planning team.
What a District Plan ought to have
i)
ii)
iii)
iv)
v)
vi)
vii)
viii)
ix)
x)
xi)
xii)
xiii)
xiv)
xv)
Background
Planning Process
Priorities as per the background and planning process
Annual Plan for each of the Health Institutions
Community Action Plan
Financing of Health Care
Management Structure to deliver the programme
Partnerships for convergent action
Capacity Building Plan
Human Resource Plan
Procurement and Logistics Plan
Non-governmental Partnerships
Community Monitoring Framework
Action Plan for Demand generation
Sector specific plan for maternal health, child health, adolescent health, disease
control, disease surveillance, family welfare etc.
14
1
The intention is to develop a fully accountable public health system through intensive
monitoring and performance standard.
District Health Plan reflects the convergence with wider determinants of health like
drinking water, sanitation, vydmen empowerment, child development, adolescent school
education, female literacy etc.
The Planning Process under NRHM
The District Health Plan should as far as practicable be an aggregation and
consolidation of the Village and the Block Health Plan.
This requires setting up of planning teams and committees at various levels Habitation/Village, Gram Panchayat (SHC), PHC (Cluster level), CHC/Block level and
District level. At Village, PHC and Block levels, broadly representative committees would
perform both planning and ongoing monitoring functions.' A similar committee at District
level would be involved in reviewing plans, based on drafting by the specialized district
planning team.
Besides large scale consultations/planning teams have to conduct household
surveys, help select ASHAs, and organize training for community groups and health
functionaries. NGOs have a role in the entire planning process.
Orientation of planning team and contractual engagement of professionals as per
need has to be the starting point for the planning process.
Village Health Plans are likely to take time and therefore District, Block and
Cluster level consultation may have to form the basis for initial District Plans. The initial
plans could be ad-hoc and for a year. The perspective plans must be on the basis of
Village Health Plan. Even then, Block will be the key level for development of
decentralized plans.
Levels of planning and the key functionaries
Village level Health and Sanitation Committee would be responsible for the
Village Health Plans. ASHA, the Aanganwadi the Panchayat representative, the SHG
leader, the PTA/MTA Secretary and local CBO representative would be key persons
responsible for the household survey, the Village Health Register and the Village Health
Plan. /
The Gram Panchayat Level Health Plans, comprising a group of villages in
many states and a single village in a few, will be worked on at the Sub Health Centre
Level/'The Gram Panchayat Pradhan, the ANM, the MPW, a few Village Health &
Sanitation Committee representatives will be responsible for the Gram Panchayat Health
Plan. They will also be responsible for over view and support for the household survey,
preparation of Village Health Registers and preparation of Village Health Plans- the
Gram Panchayat /SHC level would also organize activities like health camps to facilitate
the planning process.
15
The Cluster level will be led by the PHC/Additional PHC. Ordinarily there will
be 1-4 Clusters in a Block. The PHC Health monitoring and planning committee will
facilitate planning inputs of Panchayat representatives, along with other inputs from the
community to formulate a broad plan. In this context the Medical Officer in charge of
PHC will work in close coordination with the Pradhan/s of the Gram Panchayat/s
covered in that Cluster. The Cluster level would be responsible for over viewing the work
of Gram Panchyat/s and for organizing surveys and activities through the SHCs.
/the Block/CHC level monitoring and planning committee will review the
Block Health Plan. The Adhyakisha of the Block Panchayat Samiti, the Block Medical
Officer, the Block Development Officer, NGO/CBO representative, head of the CHC level
Rogi Kalyan Samiti will be key members of this team. Additional social mobilization
professionals and planning resource persons will also be contracted at the Block level to
develop a good Resource team at that level./The Block level Health Mission Team will
finalize the Block Health Plans. The Block Health Teams would also supervise
household and health facility surveys. They would also organize public hearings and
health camps in order to make the planning process activity intensiv^Z
The District Level Health Mission will have a Health monitoring and planning
committee responsible of providing overall guidance and support to the planping
process.
A draft plan will be formulated by the District Health Teaip, and
presented for discussion to the broader committee. After relevant discussion and
modifications in the committee, the district plan will be finally streamlined by the District
health team, which, besides a few existing government functionaries, the District Health
Teams will also have NGO representatives and a few professionals specially recruited to
meet planning and implementation needs. The District Planning team will be responsible
for household Surveys and Health facility surveys. They would also facilitate
organization of health camps and public hearings in order to make the planning process
activity intensive. The Zila Parishad Adhyaksha, the District Medical Officer, the District
Magistrate would be key functionaries of the District Team. Every district health society
would be assisted by a technical support agency, which they can choose from a number
of options.
Strategy for Technical Assistance for District Planning
The State should harness all technical resources in the State for preparation of
District Health Plans including development partners, department of community
medicine in medical colleges, NGOs with expertise in this area etc.
The State may also constitute a 10-15 member District Plan Appraisal Team
under the SHRC for appraisal of the Draft District Plan for checking Quality, Standards,
normative criterions etc before it receives the formal approval of the District Health
Mission and is sent to the State for approval.
The State Resource Center would also finalize survey formats and formats for
preparation of plans at various levels. It would also finalize with guidance and directives
from the ministry, the criteria for prioritization and indication of resources likely to be
available for each Block and convey these to the district these details as also help
develop the financial norms in conformity with these guidelines and on the basis of
inputs from Blocks and Districts.
16
he Basis -Annual Work Plans and Perspective Plans
The NRHM has a seven year time frame (20065-2012). The Perspective Plan
would be a 7 year plan outlining the year wise resource and activity needs of the district.
The Annual Plan will be based on resource availability and a prioritization exercise.
As far as possible, States should let districts know by October of the resources
likely to be available in the coming financial year.
The District should disaggregate likely budget availability on the basis of needs at
village/cluster/block levels by November. The Village, Gram Panchayat, Cluster & Block
Plans should come to district based on a prioritization exercise.
The District Health Mission Society will recommend the Annual Work Plan and
Budgets and the Perspective Plan to the State level Health Mission under the Chief
Minister.
Essential requirements for preparation for Village, Block, and District Health
Plans
>
>
>
>
>
>
>
>
>
>
>
Constitution of planning team and committees with clearly demarcated
responsibility at each level.
Engagement of professionals on contract at State, District and Block level
urgently to meet planning needs.
Broad norms for planning activities. Some idea on what is to be taken up and the
space for diversity and innovations.
Preparation of training modules for planning teams, and finalization of survey
format for household survey, Family Health Cards, Village Health Register,
mapping of non-governmental providers, and Health facility surveys.
Survey of non-governmental health providers to assess their possible role in the
District Health Plan.
Organization of large scale activities like health camps, Public hearings to make
the planning process activity intensive.
Involvement of Women’s groups and Community based organizations in planning
activity.
Release of untied grants to SHCs/ Gram Panchayats to facilitate activities.
Recruitment and relevant training of ASHAs/ANMs.
Orientation of existing health department functionaries on new ways of working.
Convergent local action along with other departments.
Framework for District Action Plan
The following framework for assessing the present situation is proposed:
Resources - Including Health humanpower, logistics and supplies; Community
resources and financial resources, Voluntary sector health resources
Access to services - including public and private services and informal health care
services; also look at levels of integration of services within Public health system
17
Utilisation of services - including outcomes, continuity of care; factors responsible for
possible low utilization of public health system
Quality of Care - including technical competence, interpersonal communication, client
satisfaction, client participation in management, accountability and redressal
mechanisms
Community needs, perceptions and economic capacities, PRI involvement in health,
existing community organizations and modes of involvement in health
Socio-epidemiological situation: Local morbidity profile, major communicable
diseases and transmission patterns, health needs of special social groups (e.g. adivasis,
migrants, very remote hamlets)
x/
Critical areas for concerted action
The following problem matrix table may be useful in prioritizing the critical areas of
concerted action. These have been dealt in detail in the following chapters.
SI.
No
Priorities
Constraints
Action to overcome
constraints
1
Functional facilities Establishing
fully
functional Sub Health
Centres
/
PHCs/
CHCs/Sub
Divisional/District
Hospitals.
• Dilapidated or absent physical
infrastructure
of
• Non-availability
doctors/paramedics
• Drugs/ vaccines shortages
• Dysfunctional equipments
• Untimely procurements
• Chocked fund flows
• Lack
of
accountability
framework
• Inflexible financial resources.
• No minimum mandatory service
provision standards for every
facility in place which makes full
use of available human and
physical resources and no road
map to how desirable levels can
be achieved
• Infrastructure/equipments
• Management support
• Streamlined fund flows
• Contractual
appointment
and support for capacity
development
staff/optimal
• Pooling
of
utilization
• Improved MIS
• Streamlined procurement
• Local level flexibility
• Community /PRI/RKS for
accountability / M&E
• Adopt standard treatment
guidelines for each facility
and
different levels of
staffing, and develop road
maps to reach desirable
levels in a five to seven year
period.
2
Increasing
and
improving
human
resources in rural areas
•
•
•
•
Non-availability of doctors
Non-availability of paramedics
Shortage of ANMs/MPWs.
Large jurisdiction and poor
monitoring.
• No accountability
• Local preference
• Contractual appointment to
a facility for filling short term
gaps.
• Management of facilities
including personnel by PRI
Committees.
18
3
Accountable
delivery
4
Empowerment
effective
decentralization
Flexibility
for
action
• Lack of any plan for career
advancement or for systematic
skill upgradation.
• No system of appraisal with
incentives/disincentives
for
good/poor performance and
governance related problems.
• Train and develop local
residents of remote areas
with
appropriate
cadre
structure and incentives.
• Multi-skilling of doctors /
paramedics and continuous
skill upgradation
• Convergence with AYUSH
• Involvement of RMPs.
• Partnership with non-State
Stakeholders.
health
• Panchayati Raj Institutions /
user groups have little say in
health system
• No village / hamlet level unit of
delivery
flexible
• No
resources
for
community action
• Referral chain from hamlet
to hospital
• Control and management of
Health facilities by PRIs
• Budget to be managed by
the PRI/User Group
• PRI/User Group mandate for
action
• Untied funds and Household
surveys
for
• Only tied funds
• Local initiatives have no role
• Centralized management and
schematic inflexibility
• Lack of mandated functions of
PRIs / User Groups
• Lack of financial and human
resources for local action
• Untied funds at all levels
including local levels with
flexibility for innovation.
to
• Increasing
Autonomy
SHC/PHC/CHC/Taluk/
District Hospital along with
well
monitored
quality
controls and matched fund
flows.
Management
• Hospital
Committees
• Evolving diverse appropriate
PRI / User framework
• PRI/User group action at
Village / GP / Block and
District level______________
• Functional
public
health
system including CHCs as
FRUs, PHC-24X7, SHCs,
Taluk/District Hospital
• Trained
ANM
locally
recruited
• Institutional delivery
• Quality services at facility
• Expanding facilities capable
of providing contraception
including quality sterilization
services on a regular basis
so as to meet existing
demand and unmet needs. z
and
local
• Lack of indicators and local
health status assessments that
can contribute to local planning.
• Poor capability to design and
plan programmes.
5
Reducing maternal and
child
deaths
and
population stabilization
• Lack of 24X7 facilities for safe
deliveries.
• Lack of facilities with for
emergency obstetric care.
and
• Unsatisfactory
access
utilization of skilled assistance
at birth
• Lack of equity/sensitivity in
welfare
services/
family
counseling.
• Non-availability of Specialists
for anesthesia, obstetric care,
pediatric care, etc.
19
6
Action for preventive
and promotive health
• No system of new born care
with adequate referral support.
• Lack
of referral
transport
systems.
• Need for universalization of
ICDS services and universal
access to good quality ante
natal care.
• Need for linkage with parallel
improvement efforts in social
and gender equity dimensions.
• Lack of linkages with other
dimensions of women’s health
and women friendliness of
public health facilities.
• Thrust on Skilled Birth
Attendants/local
appointment and training
• Training of ASHA
• New born care for reducing
neo natal mortality;
• Active Village Health and
Sanitation Committee;
• Training
of
Panchayat
members.
• Expanding the ANM work
force especially in remote
areas and in larger village
and semi-urban areas.
• Planned synergy of ANM,
AWW, ASHA work force and
where available with local
SHGs
and
women’s
committees.
• Linkage of all above to the
Panchayat committee on
health.
• Poor emphasis on locally and'
culturally appropriate health
communication efforts.
• No
community
action
&
household surveys
• Untied funds for local action
• Convergence with other
departments/institutions
• IEC Training and capability
building
• No action on promoting healthy
lifestyles whether it be fighting
alcoholism
or
promoting
tobacco control or promoting
positive actions like sports/yoga
etc.
health
• Weak
school
programmes
• Working
together
with
ICDS/TSC/CRSP/SSA/
MDM
• Improved School
Health
Programmes
• Common approach to IEC
for health
• Involvement of PRIs in
health.
• Oral hygiene movement.
• National Oral Health Care
Programme
• Oral health awareness can
be taken to the rural level.
• School
Eye
Screening
Programme. /______
• Horizontal integration of
programmes
through
VH&SC, SHC, PHC, CHC.
• Initiation and Integration of
IDSP at all levels.
Absence
of
Health
counseling/early detection.
IEC of
• Compartmentalized
every scheme
•
/
7
Disease Surveillance
for
• Vertical
programmes
communicable diseases
• No integrated / coordinated
action for disease surveillance
at various levels in place yet.
• No periodic data collection and
analysis and no district and
block specific epidemiological
data available
• Building district / Sub-district
level
epidemiological
capabilities.
20
to
for
• Entitlements of households not
defined
• No community worker
• No well defined functional
referral/transport/communicatio
n system.
• No institutionalized feedback
mechanism
to
referring
ASHA/peripheral health facility
in place
• ASHA/AWW/ANM
• Household
/facility
surveys/survey of non governmental providers for
entitlements.
• Linkages with SHC / PHC /
CHC for referral services
Information
Absence
of
a
Health
Information System facilitating
smooth flow of information.
Not possible to make informed
choices
• A fully functional two way
communication
system
leading to effective decision
making.
• Publication of State and
District Public Reports on
Health.
Planning
and
monitoring
with
community ownership
No local planning, no household
surveys,
no
Village
Health
Registers.
Habitation/village
based
household surveys and Facility
Surveys as the basis for local
action. Untied resources for
planning
and
monitoring.
Management of health facilities
by the PRIs. Thrust on
community monitoring, NGO
involvement, PRI action, etc.
Ensure
Equity
&
Health.
Promote education of women
SC/ST & other vulnerable
groups.
8
Forging
hamlet
hospital
linkage
curative services
9.
Health
System.
10.
Lack of involvement of local
community, PRI, RKS, NGOs in
monitoring
of
public
health
institutions
like
SHC/PHC/CHC/Taluk/District
Hospitals.
11
Work towards women’s
empowerment
and
securing
entitlements
of SCs /STs /OBCs
/Minorities
Standard package of interventions
under current schemes. Coverage
and quality of services to women,
SCs/STs/OBCs/ Minorities
not
tracked health institution wise. No
analysis of access to services and
its quality.
Facility and household services
to generate useful data for
disaggregated monitoring of
services to special categories.
NGO and research institution
involvement in Facility surveys
to ensure focus on ' quality
services for the poor. Visits by
ASHAs. Outreach services by
Mobile Clinics.
12.
Convergence
of
programme
for
combating/preventing
HIV/AIDS,
chronic
diseases, malnutrition,
providing safe drinking
water
etc.
with
community support.
Vertical
implementation
of
programme.
Only curative care.
Inadequate service delivery.
Non-involvement
of
community.
• Convergence
iof
programmes.
• Preventive care.
• Health & Education
• Empowering Communities.
• Providing functional health
facility [SHC], PHC [CHC]
for effective intervention.
21
13.
Chronic
burden.
disease
\
14
Social security to poor
to cover for ill health
linked impoverishment
and bankruptcy.
• Village to National level
integration.
S Stress on preventive Health
,
lEC/Advocacy
• Help of NGOs
Lack of integration of
• Policy measures.
programmes with main
health programmes.
No lEC/advocacy.
Policy
Inadequate
interventions.
Double disease burden.
Lack
of
stress
on
preventive health.
Large
out
of
pocket /• Innovations for risk pooling
mechanisms
that
either
expenditures
even
while
cross subsidize the poor or
attending free public health
are forms of more efficient
facilities- food transport, escort
demand side financing so
livelihood loss etc.
that the economic burden of
/Economically
catastrophic
disease
on
the
poor
illness events like accidents,
decreases.
surgeries need coverage for
Guaranteeing hospitalization
everyone especially the poor,
at functional facilities
Broad Outline of the Planning Process
District
District health
health planning
planning is
is viewed
viewed as an iterative and two-way process, where
District planning teams provide overall planning framework and financial parameters,
along with arranging training inputs for the Block and Village planning teams. The Village
teams would need to develop draft plans to be collated and approved at the Block level.
Similarly Block plans would be collated and approved at the District level.
It is desirable as the ongoing model of planning, for such a process to build
upwards as Village health plans -> Block health plans
District health pla^owever
this would not be possible in a full fledged manner in the first year, since formation and
orientation of planning capable bodies at Village and Block levels will take time.
Hence, during the first year, the District planning team will have to arrange five types of
activities:
>
Preparation of broad framework of planning based on assessment of current
situation, resources, NRHM priorities; drafting outline of block health plans,
disseminating these to Block health authorities, PRIs and block level NGOs
>
Consultative process involving discussion of draft block plans with Block health
authorities, PRI representatives and block level NGOs
>
Consultative process, involving discussion of key block planning issues with a
few groups of selected village stakeholders such as Panchayat heads, ANMs
and CBO representatives in each block, to get community level feedback about
major local priorities and issues
>
Consolidation of block and district health plans based on a, b and c;
22
> Technical appraisal of the Draft District Plan by District Plan Appraisal Team of
the State Government for checking quality, standards, norms etc and taking
corrective actions by the District Planning Committee
>
Presentation of the proposed District health plan to the District health society and
Zilla Parishad for final approval
>
Facilitating formation and capacity building of Village and Block planning teams
throughout the district
Components of the District Health Plan
It is envisaged that this plan would be a holistic plan but to facilitate fund release and for
monitoring; the Plan may be divided into the following components:
a. New interventions under NRHM
b. RCH II
c. Strengthening of Immunisation
d. Disease Control / Surveillance Programmes such as NVBDCP , RNTCP, NPCB,
IDD ,NLEP and IDSP
e. Intersectoral convergence activities including Nutrition, Safe Drinking Water etc
A. New interventions under NRHM:
The following is an illustrative list of activities which can be taken up under
NRHM at various levels.
23
NRHM ACTIVITIES AND NORMS
Activity
Possible processes and illustrative norms
1. Visioning workshops for
National, State, District and
Block level Mission Teams
Need for setting up teams at each level comprising existing
government functionaries and a few contractual personnel with
new skills at all levels, as per need. Orientation on the details of
the plan of action is critical for the system owning the challenge
of NRHM. Involvement of NGOs/non governmental institutions
as a team of resource persons under the framework of
NIHFW/SIHFW. It should not be a routine orientation. Costs as
per approved workshop and training norms.
2. Constitution and orientation
of all community leaders on
village, SHC, PHC, CHC
Committees
Effective institutionalization of community ownership requires
concerted efforts for appropriate selection and training of
community representatives on committees. Broadly, the effort
should be to have/at least 50 percent women on every
committee with at least 30 percent from non governmental
sectors. Reservation for SC/ST/OBCs may be considered at
various levels as per State norms. The effort has to be for a
functional system. Orientation should involve NGOs and
resource persons from outside the government system as well.
Thrust on surveys, management of accounts, functionality of
facilities, etc.
Cost as per approved workshop and training norms.
3. Untied grants to Village
Health
and
Sanitation
Committees
Every village with a population of upto 1500 to get an
annual untied grant of up to Rs. 10,000, after constitution
and orientation of
Village Health and Sanitation
Committees. The untied grant to be used for household
surveys, health camps, sanitation drives, revolving fund etc.
4. Selection and training of
Community Health Workers (
ASHAs, AWWs) etc._________
Total support of up to Rs. 10,000 per ASHA for initial
training, monthly orientation, drug kit, support materials,
travel expenses, etc.___________________________________
5.
Performance
related
incentives for ASHAs, AWWs.
While performance related incentives would come under
various programmes, the total resources should be kept aside
at the Gram Panchayat Committee at SHC level for
disbursement to ASHAs/ Every Gram Panchayat Committee
can seek replenishment of performance based funds after
disbursement to ASHAs. Rs. 5000 permanent advance may
be made available to every Gram Panchayat as a
permanent advance for this purpose. Disbursement as per
performance norms.
6. Selection and training of
non-governmental providers of
health care RMPs/TBAs
Based on a survey of non-governmental providers
(RMPs/TBAs) and their likely potential to become as qualified
as a government provider, special training programmes to
enlarge the pool of skilled health workers in rural areas
should be made. This will help in promoting common
treatment protocols and in promoting current practices and
priorities. NGOs ought to be involved in such efforts. Cost
as per standard training norms. _______________________
Tv
24
a
z7. Physical infrastructure for
village level health activity.
ASHA to work from the Aanganwadi Centre. Since
Aanganwadis have the responsibility for under 6 children,
pregnant women and adolescent girls, there is a need for
additional space for the ICDS centre that ipay be used as a
health care room. Resources can come/from existing rural
development programmes under which ICDS centres are being
constructed and provided for.
More than 2 lakh ANMs will be required to be added to the
system. Currently only 13,000 ANMs are completing their
training each year. Innovative systems involving NGOs to
introduce vocational training at High School and Ashramshalas
/'in tribal areas to work with the educated local girls to develop
them into ANMs, ought to be undertaken. In service training to
develop existing ANMs into skilled attendants at birth is
required/Duration to be worked out as per need. Involvement of
distance education systems with large local contact hours in
hospitals needs to be explored in partnership with NGOs.
Blocks need to develop their plans for filling up ANM vacancies,
identification
of selection
teams,
training
packages,
remuneration, etg/lmprovement of mobility of ANMs with a
provision for interest free loans for two wheelers could be
explored/Cosf norms to be developed in consultation with
States as per standard cost norms for training,
remuneration and orientation.^All appointments will be
contractual and based on local selection criteria.
8. Selection, remuneration and
training of ANMs.
9. Selection, training and/] There is a need to strengthen the monitoring and supervision
remuneration of PHNs at PHC role of the Lady Health Visitor, who may be called the Public
health Nurse. She should be equipped to improve skills of
level
ANMs, supervise their work, assign specific tasks to theq^/etc.
Cost norms to be developed in consultation with States as
per standard cost norms for training, remuneration and
orientation. All appointments will be contractual and based
on local selection criteria.
10. Selection, training and
remuneration of Staff Nurses
and
other
paramedics
(including AYUSH stream) at
PHC/CHC level.
The Nursing Schools put together are not producing as many
qualified nurses as needed. Given the huge demand for good
Nurses overseas, there is also a large drain of such services to
overseas demands. A thorough review of Nursing Schools,
ways of augmenting capacities as per needs, has to be worked
out in each State. Innovative training and orientation system
with the help of NGOs has to be developed to provide for
effective monitoring, etc. Existing norms to apply. Cost norms
to be developed in consultation with States as per standard
cost norms for training, remuneration and orientation. All
appointments will be contractual and based on local
selection criteria.
25
11. Selection, training and
remuneration
of
Medical
Officers at PHCs (including
AYUSH stream)
Medical Officers at PHCs have to be multi skilled and special
programmes for their orientation has to be developed in State
specific contexts. The issue of absenteeism has to be tackled
by carefully looking at the system of incentives and career
progression. Opportunities
for need based orientation have to
Qpi
be evolved..
norms to be developed in consultation
evolved./ Cost
C
....-XU
_
with States as
per standard cost norms for training,
remuneration and orientation. All appointments will be
contractual and based on local selection criteria.
12. Selection, training and
remuneration of Specialists at
CHC level.
It is a problem to get the services of Specialists at CHC level.
Flexible systems of recruitment have to be developed along
side improvement of facilities arid opportunities for hospital like
services at these institutions/cost norms to be developed in
consultation with States as per standard cost norms for
training, remuneration and orientation. All appointments
will be contractual and based on local selection criteria.
13.
Construction
and
maintenance
of
physical
infrastructure of SHCs
The Gram Panchayat SHC Committee has the mandate to
undertake construction and maintenance of the facilities. An
annual maintenance grant of Rupees 10,000 will be
available to every SHC. Specific proposal for major repairs
will have to be developed if such works are required.
Provision for water, toilets, their use and their
maintenance, etc, has to be priorities.
Construction
and
14.
maintenance
of
physical
infrastructure of PHCs
PHC level Panchayat Committee/Rogi Kalyan Samiti will have
the mandate to undertake and supervise improvement and
maintenance of physical infrastructure. Annual maintenance
grant of Rs. 50,000 to be available to each PHC. Provision
for water, toilets, their use and their maintenance, etc, has
to be priorities._______________________________________
15.
Construction
and
maintenance
of
physical
infrastructure of CHCs.
CHC level Rogi Kalyan Samiti/ Block Panchayat Samiti to
undertake construction and maintenance of CHCs. Annual
maintenance grant of Rs. 1 lakh to every CHC, to ensure
quality services through functional physical infrastructure.
16.
Procurement
and
distribution
of
quality
equipments and drugs in the
health system.
Develop capacities in States like the Tamil Nadu Health
Systems Corporation to procure quality drugs and develop
logistic arrangements for their timely utilization/ Central
government procurements as an interim measure till
capacities are developed at State! districtIBIock levels for
quality and timely procurement. Emphasis on timeliness,
transparency, and quality of procurements.
_
17. Support to BPL families for
institutional deliveries under
the Janani Suraksha Yojana.
Accreditation of government and non governmental
institutions for institutional deliveries with systems for
timely availability of financial resources to the BPL
families. States may propose enhancement of norms in
line with NCMH unit costs.--------------------------------------------------
/ 26
18. Untied grants to SHCs,
PHCs and CHCs
Every SHC to get Rs.10,0001-, every PHC to get Rs. 25,000
and every CHC Rupees 50,000 as untied grants for local
health action. The resources could be used for any local
health activity for which there is a demand.
ical
With the objective to take health care to the door step of the
public in the rural areas, especially in under-served areas,
Mobile Medical Units are proposed to be provided, one per
district under NRHM. The states are, however, expected to
address the diversity and ensure the adoption of most suitable
and sustainable model for the MMU toZsuit their local
requirements. They are also required to plan for long term
sustainability of the intervention.
19. Support to Mobile M
Units/ Health Camps
i
Two kinds of MMUs are envisaged, one with diagnostic facilities
for the states other than North-Easter States, Himachal
Pradesh and J&K. In addition, for the North-East, Himachal
Pradesh and J&K, specialized facilities and services such as Xray, ECG and ultra-sound are proposed to be provided due to
their difficult hilly terrain, non-approachability by public
transport, long distances to be covered etc.
The states are needed to involve District Health Society / Rogi
Kalyan Samiti / NGOs in deciding the appropriate modality for
Operationalization of the MMU. The provision of staff will be
considered only for the stated who will run the vehicles with
support of NGOs/RKS and in case of states outsourcing the
vehicles.
The unit cost for mobile van for staff is Rs.7.00 lakhs, mobile
unit with essential accessories costs Rs.18.25 lakhs per district
and a mobile unit with diagnostic facilities has a unit cost of
Rs.23.75 lakhs per distric^The total capital expenditure for 595
districts in the country '^estimated to be Rs. 175 crores^'The
The
and
recurring expenditure for North-Eastern states, J*
Himachal Pradesh with provision of a radiologist and an
additional driver for diagnostic van is Rs.23.71 lakhs per district
per annum. For other states,>he unit recurring cost is Rs.19.87
lakhs per district per annum. The total recurring expenditure for
595 districts in the country is Rs. 122.21 crores. '
The total capital expenditure is estimated to be Rs. 175 crores
with total recurring expenditure of Rs. 122.21 crores for the
whole country.
States to work out need and numbers for mobile dispensaries.
Health Camps as a means of mobilizing local communities for
health action and for creating demand. Unit costs to be
developed in consultation with States. Mobile Medical Unit for
each State.
27
20. Support for School Health
Programmes
/ Adolescent
Health Programmes
Innovative School Health Programmes could be taken up for a
range of issues in public health. Funding as per specific
proposals from schools/ Blocks/ districts.
Screening of school children for detection of refractive errors
and provide free spectacles to poor children.
School Health Programme should include:
Oral Health awareness programme for the children
Should also have oral/dental screening programme for
early identification and prevention.
21. Support for IEC activities
A variety of activities involving communities and also the media.
Allocations at national, state and district levels. Up to
Rupees ten per capita which should be equally spent at the
three levels (1/3,1/3,1/3).
22.
Nutrition
and
Health
Education Programmes for
women’s groups.
As a means to/Strengthen ICDS activities and to improve
cultural practices with regard to child care/ As per local
proposals for strengthening the component.
23. Resources for surveys,
camps, public hearings.
As per local needs and as articulated in the Block, District and
State level Annual and Perspective Plans.
24. Grants in aid to NGOs at
district, state and national
levels.
Up to 5 percent of the total NRHM Budget could be used as
Grants in aid to NGOs at various levels/This will improve
outreach of services and efficiency of delivery. It will include
public private partnership as well.
25. Innovation funds at all
levels.
For local action that emerge as priorities in the Block/District
Action Plans. States to appraise need for innovation and
suggest costs as per need and existing State norms.
26. Monitoring and Evaluation. Up to Rs. 5 per capita will generate an annual corpus of Rs.
150 crores. J0f this resource 25 % may be used at the national
Costs.
level, 25% at the State level and the rest at district level and
below.
________________ _____________________
27.
Management
Contingencies.
28. State
Centre
level
Costs/
Up to 6 % of the total Annual Work Plan for that year, calculated
o the basis of the total State level NRHM Plan (including the
District Plans). Resources for contractual engagement of
personnel with new skills, travel costs, etc. to be met from this.
State component and district component to be earmarked.
Resource
To be set up with an annual corpus of Rs. One crore in large
States and Rupees Fifty lakhs in smaller States/UTs. To be
used for operationalizing new ideas and for strengthening
service delivery. Resources to be used for hiring resource
persons and for field based operational activities.
28
29. National level Resource
Centre
To be set up with an annual corpus of Rupees 15 crores. To be
used for raising new ideas and for operationalizing them to
improve effectiveness of service delivery and efficiency of
resources.
30. Support to district and
Block level Resource Groups.
For development of capacities and for field based supervision of
services.
31. Research Studies
s. 5 per
Up to Rs.
pj capita will generate an annual corpus of Rs.
es. Of this resource 25 % may be used at the national
150 crores
•^/at the State level and the rest at district level and
level, 25L
below.
32. Support
activities.
for
As per specific need expressed by Districts/Blocks.
33. Capacity building needs at
all levels
To be a priority at all levels. To be designed as per local needs.
Non-negotiability of quality and standards. NGOs to be involved
as resource teams and institutions at all levels for capacity
building.
34. Costs of core, basic and
secondary health care
As per National Commission on Macro Economics and Health
assessment. The cost in the non-governmental sector is likely
to be 30-50 percent higher. State Health Missions to assess
costs based on detailed district specific exercise. Mission
Steering Group at State level can approve costs up to 25
percent more than provided by NCMH. Any further increase has
to be formally approved by the National Level Mission Steering
Group.
z35. Resources for risk pooling.
To be used as per specific state/region/district models that may
evolve, to support premium for Below Poverty Line Families.
Ceiling on premium as per UHIS - Rs. 300 for a family of five.
Nursing
As per need and specific proposals. This will also include
improvement of physical infrastructure of ANM training centres
and other nursing institutions.
37.
Improving
physical
infrastructure of SHC/PHC/
CHC/Taluk/District Hospital
Upto 1/3rd of total annual allocation under NRHM in special
focus states and upto 1 /4th in low focus states.
38.
Ambulances
for
all
PHCs/CHCs/District Hospitals.
As per case load and need. To be under the supervision of the
RKS/ User group.
39.
Telephones
for
SHCs/PHCs/CHCs/District
Hospitals.
As per need.
36.
Strengthening
Schools.
/
Planning
29
Rogi Kalyan Samitis /
40.
Hospital
Management
Committees
NRHM strategies to upgrade the CHCs to Indian Public Health
Standards (IPHS) with a purpose to provide sustainable quality
care with accountability and people’s participation along with
total transparency. To ensure a degree of permanency and
sustainability, a management structure called Rogi Kalyan
Samiti
(RKS)
(Patient
Welfare
Committee)/Hospital
Management Committee (HMC) has been evolved. RKSs are
proposed to be established in 585 rural hospitals, 3222
Community Health Centres, and 23109 Primary Health Centres
in the country. The initiative would bring in the community
ownership in running of rural hospitals and health centres,
which will in turn make them accountable and responsible-/
To motivate the states to set up RKSs, a support of Rs.5.0
lakhs per rural hospital, Rs.1.00 lakh per CHC and Rs.1.00 per
PHC per annum would be given to these societies through
states. The societies would be eligible for these grants only
where they are authorized by the States to retain the user
charges at the institution level.
An amount of Rs.29.25 crore as a seed money for
Operationalization of RKSs in rural hospitals, Rs.32.22 crores
for CHCs and Rs.231.09 crores for RKS in PHCs has been
esti m ate d.
41. Ceiling on Civil works
Up to a maximum of 33% of Annual Plan in Special Focus
States and 25% of Annual Plan in other States.
District
Up to Rupees twenty lakhs per district for surveys, workshops,
studies, consultations, orientation in the process of preparation
of District Health Action Plans.
43. Preparation of District and
State level public reports on
health
annually
by
independent agencies..
Up to Rupees Fifty Thousand per year for the preparation of
District Public Reports and up to Rupees two lakhs per year for
the preparation of State Public report on Health, based on
analysis of published reports, studies, surveys, etc.
44. Special needs of North
Eastern States
As mentioned at para 109, North Eastern States may require
relaxation of norms. It shall be taken in the appraisal process.
42. Preparation of
Health Action Plans
30
RCH-II
The second phase of National RCH 2 programme was launched in April 2005. The programme aims to
achieve national population policy goals with reference to IMR, U5MR, MMR and TFR (since
subsumed - in NRHM goals) National/State/District RCH PIPs reflect on a set of technical Strategies
and activities to achieve these goals. It is advisable to the district planning team members (members
of district health missions and other co opted members) to familiarize themselves with the state PIP
with special reference to RCH goals and strategies. This document will also be useful in guiding the
district teams in terms of how state proposes to hire additional human resources, capacity building
plans and BCC activities et(/While district plans are independent self-standing plans, nevertheless
some activities will be undertaken at the state level to support district level implementation.
C. Strengthening of Immunization
Each district is preparing immunization service delivery plans to provide efficient and safe
immunization services to all infants and PW as per National Immunisation schedul^ZThese plans
/Respond to intra district specific needs with reference to ensuring availability of immunization agents on
designated sites on session days, cold chain maintenance, monitoring adverse events following
immunization and surveillance of VIPs etc. It should be noted that ASHAs are supposed to mobilize
clients (women & children) for immunization sessiojx The plans should include activities for cold chain
equipments, support for vaccine delivery, and support for ASHAs and requirements for AD syringes in
the district. The communication activities for improving immunization coverage and for mobilizing
clients on the designated NIDs have to be reflected separately.
D. National Disease Control Programmes
7.
Revised National Tuberculosis Control Programme (RNTCP)
RNTCP incorporates elements of internationally recommended elements of Directly Observed
Treatment (DOTS) short course strategy. The district level of objectives of RNTCP in
conformity with national programme includes annual case detection rate of 70 per cent,
treatment success rate of 85 per cent^Tlie programme aims at improved treatment seeking
behaviour of TB suspects, quality assured sputum microscopy, ensuring proper categorization
of TB patients and improving treatment compliance by ensuring directly observed treatment
and uninterrupted supply of quality assured drugs.
ii.
National Vector Borne Diseases Control Programme (NVBDCP)
The NVBDCP was initiated in the year 2003-2004. It is an umbrella programme for prevention
and control of vector borne diseases including Malaria, Failaria, Kalzar, JEJE and Dengue.
Under the programme comprehensive and multi sectoral public health activities are
implemented. Districts teams should review incidence and prevalence data available for these
diseases in the district through surveillance activities and plan as per national strategy adapted
to address local needs;
Vector borne diseases like Malaria, Dengue and Japanese encephalitis are outbreak prone
diseases and therefore during formulation of the district health plan, epidemic response
mechanism should also be outlined.
31
Hi. National Leprosy Eradication Programme
The programme was initiated as a central programme in the year 1955 and Multi Drug Therapy
(MDT) was introduced for treatment of leprosy in 1982. Since then the programme has
achieved tremendous success in bringing down leprosy burden and leprosy has been
eliminated as a public health problem (PR<1/10,000 population) at National level in December
2005. The programme now aims at providing quality leprosy services through General Health
Care System, to eliminate leprosy at remaining state, district and block level and to enhance
disability prevention and medical rehabilitation services for deformed leprosy patients/
iv. National Blindness Control programme
The National programme for control of blindness was launched in year 1976 with a goal for
reduction in prevalence of blindness from 1.4 percent to 0.3 percent. The four-pronged strategy
refers to strengthening service delivery, developing human resources for eye care, outreach
activities and developing institutional capacities./
All school children in the age group of 10-14 years should be screened for refractive errors.
Percentage of children detected with refractive errors should be
■
Integrated Disease Surveillance Programme
Integrated Disease Surveillance Project is a decentralized state based surveillance programme
for the common communicable and non-communicable diseases. It is intended to provide
essential data to monitor progress of on going disease control programme and also to detect
early warning signals of impending outbreaks and help institutions to develop an effective
response in a timely manner/The project has been phased out as per the following plan:
>
Phase 1 states, which will implement IDSP beginning in FY 2004-05 are Andhra Pradesh,
Himachal Pradesh, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Mizoram and
Kerala.
>
Phase 2 states/UTs, which will implement the IDSP beginning in FY2005-06 are Chhattisgarh, Goa,
Gujarat, Haryana, Rajasthan, Uttaranchal, West Bengal, Manipur, Meghalaya, Tripura, Chandigarh,
Pondicherry, and Delhi.
>
Phase 3 states/UTs, which will implement IDSP beginning in FY2006-07 are Uttar Pradesh, Bihar,
Jammu and Kashmir, Jharkhand, Punjab, Arunachal Pradesh, Assam, Nagaland, Sikkim, A &
Nicobar, D& N Haveli, Daman and Diu, and Lakshadweep.
32
I
The diseases under surveillance are as follows:
Regular Surveillance:__________
_________ Classification of Disease
Vector borne disease_____________
Water borne disease
Respiratory disease_________
Vaccine Preventable disease
Disease under eradication_____
Other conditions____________
Other international commitments
Usual
Clinical
syndromes
death/hospitalization)
Skin disease
(causing
Name of the disease
Malaria
______________________________ _
Acute diarrhea______________________________
Typhoid___________________________________
Tuberculosis_______________________________
Measles, Diphtheria, Pertussis, NNT_____________
Polio_____________________________________
Road traffic accidents________________________
Plague, Yellow fever_________________________
Meningo encephalitis, hemorrhagic fevers, other
undiagnosed conditions.______________________
Leprosy
Sentinel Surveillance:
• Sexually transmitted diseases / Blood borne: HIV/HBV/HCV
• Other conditions: Water quality, outdoors air quality.
• Regular Periodic Surveys: NOD Risk factors
vi. National Iodine Deficiency Disorder Control Programme
The NIDDCP aims to control iodine deficiency through:
1. IDD Survey!resurvey
2. Supply of iodated salt
3. Establishment of IDD Control Cell
4. Establishment f IDD Monitoring L7a
5. Health Education and Publicity/
E: INTERSECTORAL CONVERGENCE ACTIVITIES
.■ As the indicators of health depend as much on drinking water, nutrition, sanitation, female
literacy, women’s empowerment as they do on functional health facilities, NRHM seeks to adopt a
convergent approach for interventions under the umbrella of the district plan which seeks to integrate
all the related initiatives at the village, block and district levels/ While substantial spending in each
of these sectors would be from the concerned departments, theA/illage Health Plan /District Plan
would provide for some catalytic resources through Untied Grants for convergent action.
Also, as reflected in the HIV/AIDS and RCH convergence document, sub-district activities for
prevention of HIV/AIDS are also to be planned as an integral component of the DHAPs/Possible
demand generation activities for utilizing services offered such as PPTCT, VCT and ART, should be
explored.
There may be variations across the states i/ntegrating DHAPs with Safe water supply and
rural sanitation in the initial years. However eventually district health missions should aim to integrate
these programmes alsq-to achieve desired synergy in activities leading to comprehensive response for
health determinants.
33
School Health Check up Programme in Gujarat
Background
■
The first school health programme in the country was started by Sir Sayajirao Gaikwad, King of
Baroda, in 1909.
•
The Bhore Committee (1946) reported that School Health Services were practically non existent in
India and where they existed were in an underdeveloped stage.
•
The Secondary Education Committee (1953) emphasized the need for medical examination of
students and a school feeding programme.
Government of India
Gol launched a Special School Health Check up Programme in 1996 which was implemented in co-ordination
between DoHFW and DWCD with the following objectives:
>
>
>
>
Early detection of health related problems that are commonly occurring amongst primary school
children.
Building of health awareness in the community through primary school, children.
Screening of children for major illnesses for appropriate and timely referral
Follow up arrangements for detailed check up and treatment of referral cases at Government Health
facilities so as to provide specialist treatment and care to needy students.
The Multi Purpose Workers (MPWs) did the primary screening and referral services were provided at primary
Health Centres (PHCs). The programme was however discontinued.
GcverrmentofGujarat
o
Since 1997, the single largest health programme operating in the state.
o
Organisation: State level Steering Committee chaired by the State Health Minister, with Chief
Secretary, Additional Secretary (Health), Additional Secretary (Education), Additional Secretary
(Finance) and Members of Legislative Assembly as members.
d
Implementation: Microplans are prepared at PHC level which include details the schools and
anqanwadis to be visited for health check ups and list the other activities to be carried out. All these
plans are collected, collated and analyzed by the state level Health Education Bureau to provide the
State Plan for School Health Scheme.
o
Services provided: Of a total of 8,692,436 children, 8,324,661 were examined in the year 2005-06.
Children with minor ailments like anaemia, worm infestation, ear discharge, scabies, boils are treated
on the spot while those requiring the services of specialists are sent to related referral centers.
Children with refractory errors are provided spectacles free of cost. Children suffering from heart,
kidney and cancer diseases are provided treatment at apex tertiary care hospitals. Not only is the cost
of treatment borne by the state government, referral transport is also provided. If needed, specialist
treatment outside the state is also provided. The scheme is currently being evaluated.
o
Budget: of Rs 500 lacs under the plan budget.
o
New initiative: “Health Promoting School" has been started with assistance from WHO in four districts
and one urbln area. The programme will take care of Quality of Water and Sanitation in schools and
augument capacity building of teachers so as to achieve holistic and sustained promotion of health in
schools. /
34
I
_____________________________________ _ ________________________ _—
Health Sector Reforms -Rogi Kalyan Samiti /Hospital Management Society
Rogi Kalyan Samiti (RK$) / Hospital Management Society (HMS) with the
structure of the General Body responsible for policy formulation and decision making
and the Executive Body for implementing the decisions started to reduce infant, child
and maternal mortality in the State of Madhya Pradesh revolutionized the way of running
hospitals in the State. The exemplary task done in Indore under the RKS got
international recognition through the Global Development Network Award, 2000 as the
most innovative development project. It proved that people essentially want to help
themselves and good governance is about showing them the way and not interfering.
RKS is the way of finding scope to upgrade infrastructure and facilities in public
hospitals, which is otherwise difficult to do through government budgetary support.
Other than this the charter of RKS includes in its responsibilities other roles such as
creation of a better atmosphere, management training, orientation and incentives for
staff and the management of resources, equipment and waste etc. This is made
possible by utilizing the additional resources created through cost recovery schemes,
using hospital property and land and also by freely applying for user charges. It also
reflects communities capacity to pay for hospital services and could be considered as an
indicator in terms of the movement towards increased hospital autonomy. Good hospital
management is crucial in relation to the risk of death due to complications in pregnancy
and childbirth, infancy and early childhood. Additionally, hospitals provided
indispensable support for the primary health care services needed for preventive
functions.. The underlying theme of decentralization in the concept of RKS to increase
income through non-budgetary resources has also been accepted by Andhra Pradesh
and Gujarat with different objectives such as for increasing financial reliance and for
delegating powers to Regional Directors in these States. In the hospitals, the heads of
department are responsible for decisions taken in their wards, including the use of
additional funds generated, and decision relating to staff. This active involvement of
physicians is considered to be one of the success factors of the RKS. Still, a number of
issues are needed to be addressed before RKS could serve as a model for total hospital
autonomy such as unequal distribution of the non- budgetary resources as small
hospitals has limited capacity to generate resources; pattern of utilization inclined
towards improving physical infrastructure than more complex managerial issues; dual
management and administrative system at the hospital level which could be rectified
through channeling of government budgetary allocations though the RKS and giving
additional freedom and autonomy to the hospital staff for local level decision making,
missing in the quasi-government controlled RKS and also ill defined relationship
between the RKS and the State government. Nonetheless, RKS seems to be the only
way to reform the public health care delivery system in general and public hospitals in
particular
Or
35
ChE0J
3
Resource Allocation and Financial Norms
The NRHM integrates all related, inter linked and stand alone schemes in the health sector including RCH,
National Disease Control Programs (NDCP), Integrated Disease Surveillance as well as new initiatives
proposed under NRHM and National Commission on Macro Economics and Health. A common and flexible
fiscal pool has been designed to cover all NRHM activitie/and various financial resources including external
aid have been rationalized and compressed into four categories. These include:: (i) operational support to
states (released through treasury route); (ii) operational cost of institution supported by MOHFW; (iii)
activities centrally implemented; and (iv) activities in the State programme Implementation Plan (released
through Integrated Health & Family Welfare Societies). Support for the District Health Action Plans falls
under the category of support to activities in the State PIP.
The Financial norms under NRHM integrate and harmonize existing norms for all schemes subsumed
under the NRHM including NDCP, RCH and Integrated Disease Surveillance Programme The district
health mission will have total flexibility to include activities that are relevant to needs of the district
keeping in view of the implementation guidelines of the various disease control programme. However,
all district plans need to include some components such as Jannani Suraksha Yojana, ASHA in high
focus states, Mobile Medical Units, Untied Grants to Facilities and VH&SC, Funds to Rogi Kalyan
Samitis, camps and sterilization compensation mandated by the Centre from time to time in national
interest.
Approaches for Equity based Resource Allocation:
The MOHFW has used an equity-based approach to allocate RCH/NRHM Flexible pool to various
states. While the overall allocation is done on the basis of population, an additional weight has been
assigned to the NRHM priority states to ensure allocation of higher resources to more needy states...
The Eight EAG states have been assigned weight of 1.3, North Eastern States have been assigned
weight of 3.2 and Other Non-EAG / NE states have been assigned weight of 1. This approach ensured
more resources to the states that are critical for achieving outcomes envisaged in NRHM.
Suggested options that the states may choose to allocate funds to the districts
a) Equal Distribution of resources for all districts: In this approach.out of the total resources allocated
to the state by MOHFW 10% will be earmarked for utilization at the state level. The balance 90% is
distributed equally among the districts by dividing this amount by the number of districts in the state.
The average resource available to the Districts may go up by 25% to 35% depending upon the
utilization and reporting by the districts. While the main advantage of this approach is simplicity, it
fails to address specific needs of districts located in backward regions of the state and hence not
equitable. Also, this approach assumes that all districts are of equal size, which in reality is not the
case in most states.
36
b) Equity based distribution based on socio-demoqraphic characteristics: Using socio demographic
variables as criteria for allocating resources to districts is probably a more equitable method...
These criteria could be rural/urban distribution, proportion of SC/ST and vulnerable groups or
districts with adverse health indicators. Either a single or a combination of such criteria can be used
to rank the districts and allocate resources accordingly. It should also be based on District profile
Template-1 as shown in page 17 of this document. A simple example is shown below
_______ Socio-demographic criterion_____
% of Urban population
% SC & ST population
% deliveries by skilled attendant
HIGHEST ATTAINABLE SCORE
Current level
>75%
50-75%
25-50%
<25%
>25%
10-25%
<10%
>50%
25-50%
<25%
Score
1__
2
3
"4
__3__
2
_1__
_ii_
2
3
10
Although the socio-demographic criteria mentioned in the document would be applicable
incase of most of the communicable diseases, the endemicity of the diseases particularly
malaria should also be considered as a criterion for more equitable resource allocation.
The highest possible score for a district in the example shown in the table will be 10 (4+3+3).
The districts can be distributed in to 3 broad groups: (a) most vulnerable (with score of 7 and
above); (b) vulnerable (scores of 4-7); and (c) least vulnerable (<4). For each group a
vulnerability weight can be added as done by MOHFW. For example, 30% for most vulnerable,
and 15% for vulnerable districts. For applying this formula, the average resource per district
provided in Annex I can be multiplied with 1.3 and 1.1 respectively to arrive at estimated
allocations for most vulnerable and vulnerable districts respectively. The remaining balance
can be equally distributed among the least vulnerable districts by just dividing it by the number
of such districts.
c) Need based approach: A need-based allocation is another option, which will be responding to
specific health needs of a district.
Administrative Expenses:
The administrative expenses including consultants for program management support units and travel
expenses (as per the State Govt, norms) should not exceed 6% of the total NRHM outlay for the state
for the financial year. It is important to ensure that any other administrative expense reflected in the
specific programme/scheme guidelines also should be within this overall ceiling of six percent.
Vector Borne Disease Control Programme requires more intensive supervision and monitoring at field
level particularly in reference to spraying for vector control and surveillance activities. Hence, travel
expenses should be provided as per the need of the districts indicated in their district health plans.
37
RNTCP has provided support to the states for intensive monitoring for quality microscopy and to
ensure DOT is being implemented as per the national programme guidelines .In view of this the
programme has provision for contractual staff and their mobility at the district level. The programme
therefore, has laid down norms and guidelines for expenditure of the same at the district level. Para as
given below may be appended.
“RNTCP requires supervision and monitoring as per guidelines of the programme so that quality
sputum microscopy is being performed at Designated Microscopy Centers and
DOT is being
administered to the patients regularly as required .It also needs to upgrade the records and provision
of TB numbers to the registered patients. Hence, travel and other expenses should be as per
programme guidelines”.
Fund Flow & Reporting:
□ In the First year, after approval of the State PIP, funds are transferred to States in 2-3 trenches.
□ States will transfer these funds to Districts as per the approved DHAP
□ Districts will in turn transfer these funds to Hospitals/CHC/PHC/Sub Centres/ Other
implementing agencies.
□ The PHC/CHC/Sub-Centres/other implementing agencies will report back the expenditure
incurred to the District
□ Within the District Health Society there should be a separate RNTCP account with DTO as one
of the signatory for flow of funds.
□ For the smooth release of funds to the state and subsequently to the districts, timely
submission of following financial reports is critical.
>
>
>
District compiles the data and sends the expenditure report to the State once every
month
State compiles the data and sends the SOE (FMR) to Centre once every quarter
Districts will submit Utilization certificates to the states as soon as possible.
The districts should closely monitor the use of advances made to various implementing
agencies
(govts and non govts) and ensure that they are settled within defined time frame.
Delay in the submission of UCs and non-settlement of outstanding advances could result in
restricting timely fund flow to the states and the districts.
PIP approved
by GOI
Funds
transferred
to States
Funds
Transferred to
Districts
Reporting Back
Of Exp. to Centre
With UC and Audit Report
.....
Transferred to
PHC/CHCZ
Other Impl.
agencies
Reporting
Back of Exp. to
State
Reporting
Back of Exp. From
PHC/CHC/Other^
Imp. Agencies ’
to
District
38
Delegation of Financial Powers:
A model delegation of Financial & Administrative Powers for smooth and efficient working of the
District Health/FW/RCH Societies in the following table. This may be adapted or modified depending
on the local requirements.
Type of expenditure
Authority
A: Release of funds to Hospitals/ hospital societies, block Medical
Officers and other implementing agencies as per State
Government approved norms and/or proposals approved by State
Government.
Executive Secretary
/ Member-Secretary
of the concerned
Programme
Committee
Extent of power
Full powers
B: Release of funds for implementation of plans / allocations
approved by Governing Body / Executive Committee.
C: Expenditure proposals not covered under categories A and/or B
C-1: Procurement of goods
Chair-person,
Governing Body
More than Rs 2.00
lakhs and upto Rs.
5.00
lakhs
per
case.
Chair-person,
Executive
Committee
Upto Rs. 2.00 lakhs
per case.
Chair-person,
Governing Body
Upto Rs. 1.00 lakh
at a time subject to
a maximum of Rs.
10
lakhs
per
annum.
Chair-person,
Executive
Committee
Upto Rs 50,000 at
a time, subject to a
maximum of Rs.
5.00
lakhs
per
annum.
MemberSecretaries of the
Programme
Committees
Upto Rs 5,000/- at
a time subject to a
maximum of Rs.
1.00
lakh
per
annum.
C-2: Repairs and minor civil works
C-3: Procurement of services for specific tasks Including
outsourcing of support services.
C-4: Miscellaneous items not mentioned above such as hiring of
taxis, hiring of auditors, meetings and workshops, training,
purchase of training material/ books and magazines, payment of
TA/DA allowances for contractual staff and/or non-official invitees
to DHS meetings and/or officials deputed to meetings outside the
district.
39
Note:
1. During the Financial year, no authority can exercise the powers beyond the amount provided
against that item in the annual work plan and budget for that financial year approved by the GOI.
2. A higher authority in the District Health & Family Welfare Society may exercise the power
delegated to the authority subordinate to it.
3. No appointment in District Health & Family Welfare Society will be made by any authority except
on the recommendation of the selection committee duly constituted by Chairperson.
4. Two functionaries of District Health & Family Welfare Society will sign every cheque.
5. Purchases under C-1 will be made through a duly constituted purchase committee with the
approval ofChairperson of the Governing Body of the District Health/Family Welfare Society.
Delegation of Administrative and Financial Powers
Annexure VII provides an overview of the approved Delegation of Administrative and Financial Powers
under the Mission against key NRHM activities.
40
4
Conducting Situational Analysis
3.1 Preparatory Phase
Data Collection
As a preparatory exercise for the formulation of DHAPs; each district team will undertake a detailed
situational analysis. This will entail conducting facility survey, household survey and ^dcess to
secondary data sources, compiled service statistics and also any published studies Many times
tkjese datasets can be accessed through the state Monitoring and Evaluation cells. Availability of
/informatioq will enable in providing with a snap shot of where the district stands with respect to key
programme indicators. This apart, the exercise will provide with an overview of availability of other
resources (human and financial) and gives options for pooling and optimum utilization of resources.
Facility Survey
In order to set up benchmarks for service quality and utilization, and identify input needs, facility
surveys will have to be conducted. These surveys will provide critical information in terms of
infrastructure and human resources gaps those needs to be addressed through planning process.
Facility survey will also help in monitoring service quality standards by RKS. Thus facility survey for
each facility will be critical database for input planning and assessing service quality from clients and
providers perspectives Self administered tools for facility survey can be used for gathering information
through Medical officers and ANMs
Household Survey
HH surveys are to be conducted at the village level by a team of ASHA, AWW and Trained TBAs. The
main purpose of this exercise is to understand the health care needs of the rural population, resource
mapping and also to assess as how other determinants of health influence health of HHs such as
drinking water, sanitary latrine, employment and access to other requirements. To ensure community
participation in planning and monitoring, household survey through village health teams specifically,
ASHA and Anganwadi workers have been strongly advocated. Data collected from household survey
will be used in preparing village health registers that will serve as an input tool for developing village
health plan. The village health plan, thus formulated will be used at the local level and activities
monitore J accordingly. However this might take some time to start in the districts as concept of village
health planning will take some time to sink in
41
These surveys would be used as planning and monitoring instruments and not for any national
reporting system. The intention is to assess the needs of the District through household and facility
surveys that track the baseline information of the institutions and households. These surveys along
with secondary data available would form the basis for planning annually for the improvement of
indicators and facilities, /he base line through the facility survey will provide every institution an
opportunity to assess its present performance, plan it’s human and financial needs for the forthcoming
years and indicate the service guarantees that the institution will provide with the additional flexible
finances and human resources.
The Facility and the Household Survey would also be public documents kept in the
facilities and the Anganwadis respectively for public scrutiny.
The formats for household and facility surveys are at Annex- l-lV
3.2 Situational Analysis
In this section,, the profile of the district in terms of its background characteristics, health facilities (both
public and private), functionality of health facilities, logistics, coverage of ICDS programmes,
availability of elected representatives of Panchayat Raj institutions and presence of NGO’s, CBO’s in
the area will have to be captured. Profile of the district helps to understand the district better and also
to identify the constraints particularly in terms of size of villages, access to villages etc. For instance
economic classification of workers helps to understand the size of disadvantaged groups to better
focus on issues of equity V
The first template is on district profile wherein general information of the district in terms of its social
demographic characteristics has to be collected. As far as possible, it is better to use information from
2001 census. In case, there is any latest information available from an authentic source or other largescale data sets, it can be used but the source of information will have to be quoted. The template can
have district-specific information on one column and state-specific on the other. This will give an idea
of how the district is placed in comparison to the state.
These templates are generic in nature and more data inputs may be included/The District Plan should also
address the specific requirement of the Districts. Area specific concerns like flood problem, drought problem,
needs of sc/st, health problems due to industries, water shortage should be highlighted and addressee/
District Profile-Template 1 - < 400,000 (urban) currently under NRHM
S.No.
2
3
£
5
_______Background Characteristics
Geographic Area (in Sq. Kms)______
Number of blocks________________
Size of Villages (2001 Census)
1-500
501-2000
2001-5000
5000+________________________
Number of towns________________
Total Population (2001)
-Urban
- R u ra I
_____ District
% to total
Number
State
Number
42
Sex Ratio (F/MM000)
• Population Sex Ratio
• Child Sex Ratio____________________
Decadal growth rate_______________________
Density- per sq. km._______________________
Literacy Rate (6+ Pop)
-Male
-Female_________________________________
%SC population
%ST population
No. of schools
No. of Anganwadi Centres__________________
Length of road per 100 sq. km._______________
% of villages having access to safe drinking
water facility______________________________
% of households having sanitation facility
(Specify Type -sewer, septic tank)___________
% of population below poverty line____________
Health Status
6
1_
8
9
10
12
13
14
15
t
16
17.
18.
19
Morbidity
Male
Female
Child
Mortality
MMR
IMR____________
Health ResourcesFacilities (Specify level of Facility like
Subcentre)
Personnel(Sanctioned Vacancy)
Finances(Requirement and Releases)
1. Birth rate and death rate
2. Fertility rate.
3. Disease maximum Disability.
4. High Risk Groups______________________
B.To link with the nutritional determinants1. % of Infants with low birth weight.
2. Weight for Age no. above 90%,
3. No between 60%-80%,
4. No. below 60% weight for age____________
No of Primary schools
No of Primary school teachers
No of children enrolled(Age wise)
(All relevant data needed to Start School
Health Programme)
43
Broadly, interpret the salient findings in terms of key highlights:
□ Specific Urban Health Projects may be formulated based on the relevant guidelines only in
respect of cities/urban areas having population of one lakh or more.
□ Population-Rural/Urban Composition: For urban areas of the district with a population upto 1
□
□
□
□
□
□
□
lakh, consider formulation of urban health sub plan in case there is substantial urban poor
population with adverse health indicators. Similarly district may consider planning for
interventions to enhance access in tribal blocks.
Distribution of Villages by population size. This will have implications on how to organize
services in outreach, assignment of villages to the additional ANMs and ASHAs, addressing
logistics issues for outreach services and communication activities.
Identify blocks with higher proportion of small villages and poor roafi connectivity. This will have
implications for designing outreach service delivery interventions z
Sex ratio: It is important to assess child sex ratio and plan interventions for effective
implementation of PC-PNDT act as well as advocacy
Distribution of Anganwadi Centres
Literacy-male to female: Will help in designing of appropriate communication activities using
more visuals than written material text
,
Availability of civic amenities such as safe water supply, sanitary latrines. This information will
help in planning for interventions with support from concerned line departments to increase
access to safe water and sanitary latrines.
Economic classification especially BPL distribution will help define estimations of JSY clients
and also design interventions based on alternative health financing mechanisms...
3.3 Public health facilities and functionality of facilities-Templates 2, 3 & 4
Availability of health facilities and human resources are essential prerequisites to ensure health
services. Firstly, it is important to know the different types of public health institutions in the district and
secondly it is necessary to understand how many institutions are actually functional in terms of
availability of critical staff position so that one gets a realistic picture of centres that are able to provide
services.
It is therefore, essential to know essential gaps of obstetricians, pediatrician, and
anesthetists, staff nurses at CHC/PHC levels.
Public Health Infrastructure in the district -Template 2
Health Facility
Number
Government Buildings
Rented
District Hospital____________
Medical College Hospital_____
AYUSH Colleges and Hospitals
Sub District
____________
Rural Hospitals ___________
UFWC ________________
CHC including Identified FRUs
BPHC
______________
Sector PHC
_______
Subcentre_____________ _
Ayurvedic Dispensary_______
Homeopathic Dispensary____
44
Note: The above list of health facilities is an illustration. Classify the type of health facilities as per the
state classification
If possible a Map the facilities in the district by blocks should be included as part of the DHAP.
uman Resources in the district -Template 3
Staff
Sanctioned
In-Position
Vacant
Chief Medical Officer/AYUSH
Deputy Chief Medical Officer/
Additional CMHOs, Additional DHOs
or RCHOs/AYUSH______________
Medical Superintendent-CHC______
Medical Officers including
specialists ( sub district facilities) /
from AYUSH also_______________
Medical Officers/from AYUSH also
Lady Medical Officers only if there is
any separate cadre in the state)
Lab technicians_________________
X-ray technicians________________
Staff Nurse_____________________
LHV__________________________
ANMs_________________________
MaleMPWs
__________ _
District TB Officer_______________
Senior Treatment Supervisor (STS)
Senior TB Laboratory Supervisor
Staff provided under the Vector
Borne Disease Control Programme
like District Malaria Officer,
Assistant Malaria Officer and,
Malaria Inspector________
Mention any other category —
45
Functionality of District Hospitals ,CHCs, PHCs and Subcentres (in terms of availability
of critical staff position)- Template 4
No. of facilities
Critical Staff
1
District
Availability of staff
needed for service
Guarantees
CHC
Ob&Gy specialists
(either qualified or
trained),
Pediatrician
Anesthesist (either
qualified or trained)
at identified FRUs
PHC
a
Of
Availability
medical officer at
PHC
Names
Sanctioned
In Position
.
— I —
Vacancy
Indicate blocks
where more
than 20
percent posts
are vacant______________ __
Indicate PHCs,
Sub Centre
with
more than
Availability of an
10
percent
ANM at sub centre
posts are
(resident at sub
________________
vacant
_______ ______________
centre^
*Health personnel on the contractual basis should be reflected separately./
3.4 The analysis section:
Discuss templates 2, 3, and 4 together and draw inferences of the extent to which the public health
infrastructure is geared up to provide health services and identify gaps.
that are functional- analyze by categories
.
□ Percentage of facilities
□ Based on the spatial distribution of facilities and availability of staff, identify institutions that could be
□
strengthened on a priority basis for providing service^ Consideration could be made to issues such as
road connectivity with such institutions and the population it caters. This will also help in identifying
blocks that need additional inputs for making services available to the community or where demand
side interventions such as ASHAs will be needed on priority/
Functionality of a facility is also highly dynamic. As staff transfers are frequent and non-availability of
critical staff such as specialists at FRUs or ANMs at SCs result in serious disruption in services the
analysis should identify such recurrent problems with a view to discuss the probable solutions in block
meetings.
46
3.5 Logistics- Template 5
The existing situation of logistics management practices has to be captured. This is essential
because, several studies have pointed out poor storage practices resulting in high wastage of
commodities. Even though training on logistics management has been imparted, this seems to be a
neglected area and the mechanism operating at present is more of a push system rather than need
based supplies. Streamlined logistics systems can help provide medicines, contraceptives, vaccines
and other consumables to service providers in adequate quantity at right time and place and also help
to reduce wastage.
Status of Logistics-Template 5_____________________________
___ ________________ Logistics Elements_________________
Availability of a dedicated District warehouse for health department
Stock outs of any vital supplies in last year____________________
Indenting Systems (from peripheral facilities to districts)_________
Existence of a functional system for assessing Quality of Vaccine z
.
J
Description
In line with this several questions need to be answered and they are:
□ Does the district have storage problems? Are supplies received from various National Health
Programmes (NHPs), ffCH and also from state resources are stored separately and separate stock
registers maintained? Is there a need to reorganize the logistics function in the District to streamline
storage of supplies?
It will give some indication of how logistics system is functional in the district. These vital supplies
could be immunization agents, condoms, IUDs, tubal rings, Vitamin A, ORS, Drug kits under RNTCP
etc. description should highlight if there is, any pattern in the stock outs i.e. in particular blocks or
supplies related to specific programmes.
□ An assessment of indenting systems will be very useful to understand if supplies are made on the basis
of Pull or Push factors. This will also let the programme managers assess/fime lag in indenting and
actual supplies and adequacy of supplies reaching the peripheral facilities—'
District programme managers should assess the functioning of the reverse cold chain and the actions
they take based on feedback reports of the vaccine quality. This could be a very sensitive indicator of
the functionality of cold-chain logistics system.
3.6 Training Infrastructure-Template 6
Continuous capacity building of health personnel is one of the most important strategies envisaged in
NRHM and RCH II programmes. A number of training programmes have been suggested in the different
programmes so as to equip providers with knowledge and skills for delivery of services in adherence with
standards of care. In order to carry out these trainings, it is imperative to have good training infrastructure
competent staff members at the training institutions and necessary teaching aids/ Information on training
infrastructure along template 6 has to be collected by the district if there are any training institutions in the
district. These institutions could be an ANM training centre, District training team or centre or even the
regional training outfits in from of RFPTCs, Divisional Training centres etc. Private sector nursing training
institutions should also be considered in this analysis.
47
If there is more than one institution, information on all the training institutions will have to be collected (For
instance, the district has ANM training school and RFPTC then Template 6 will have to be used twice and
information presented separately).
Status of Logistics-Template 6
___________
______________________________ Details about the training institution/s
Name of the Institution:________________ ______
_______________
Physical Infrastructures
Availability of lecture halls, place for training faculty, residential
accommodation for trainees ( men and women), dining hall, furnitures,
safe drinking water and electricity etc
Key issues
Provide details of Faculty (Sanctioned and In-position) with designation
and specialization
_________________ __________
Availability of Teaching Aids, computers etc.
Assessment of availability of common audio visual aids at the facility
Availability of annual training plans for the last year and achievements of
the plan?
_________
Availability of training calendar for the current year with clear cut time
line for the training activities.
Training activities under NRHM:
i)
Orientation / sterilization workshops on NRHM
District level officers of related departments, sub district level
officers, elected PRIs, field NGOs, faculty of ANMTCs/DTCs,
block panchayat and Gram panchayat
H)
Training for strengthening of health system
ASHA training
Skill based trainings
The districts are required to indicate the trainings conducted for all
categories of health personnels with reference to the training load. The
cumulative number of trained manpower and the number of trained
during the current year along with percentage of achievement may be
specified._____________________________________ ____________ __ ______________________________ '
The role of the Medical Colleges in training under National Disease Control Programmes should also be
included.
3.7 BCC Infrastructure-Template 7
Another important crosscutting support programmatic area is the BCC. It will be useful to assess availability
for
assessing
of resources to undertake demand generation activities in the district??’ Hence
I'
r
y
~Z BCC
It
is
suggested
to
collect
this
infrastructure in the district following information has to be collected. I
information from the 1/C of the IEC/BCC in district.
48
BCC Infrastructure in the district-Template 7___________
Human Resources for BCC i.e. District Media officers, Dy
Media officers and block level staff
Any trainings the staff has undergone in media planning or
material development in past five years
Any functional Mass media audio- visual aids such as 16
mm projectors, Video cameras, VCD/DVD players________
-Did the district prepare a BCC plan in the past year?
-If yes, what BCC activities were planned and undertaken?
-In the absence of plan, find out what BCC activities were
undertaken?_______________________________________
Are there other institutions available in the private sector for
conducting communication activities using modern media or
folk media???
The above information and the areas of strengthening will be useful in planning for necessary inputs at the
time of formulating the district health action plan.
3.8 Private Health Facilities and Type of Facilities - Template 8
In order to increase access to health care services, there is a need to explore the presence of private
sector facilities in the district.z Furthermore, with the government seeking public-private partnership
through its programme, it becomes more important. Forging alliances through various schemes will
enable in addressing the problem of access. Hence, there is a need to collect information on the
number of private institutions and type in terms of:
Private Services Facilities
Number and location in
case of sub district
facilities.
Multi-Specialty Nursing Homes____________________________
Solo Qualified Practitioners___________________________ ____
Practitioners from AYUSH________________________________
Approved MTP centres in Private sector_____________________
RMPs (Less than formal qualified practitioner)________________
Number of nursing homes with facilities for comprehensive
emergency obstetric care_________________________________
Accredited centres for sterilization service____________________
Accredited centres for IUD services /
□
District may have some multi specialty nursing homes. It will be useful to have information on the
maternity nursing homes so that these centres can be contracted for services under JSY after
accreditation. Similarly, surgical nursing homes could be accredited for providing clinical methods
of family planning under PPP.
Solo practitioners can be important allies in enhancing access to services. In case district is
planning to have social franchising models for RCH services, programmatic interventions could be
worked out accordingly. Social franchising through these solo practitioners could cover services
under the package of Primary RCH services, VCTC, STI management, microscopy and treatment
49
centre under RNTCP. Private provider facilities may be used as training sjtes., if they evince
interest.
/
Mainstreaming AYUSH is also one of the core strategies in the NRHM. Information about
availability and spread of the qualified AYUSH practitioners in private sector will also help in
developing programmatic interventions.
/ □
Information on availability of approved MTP centres in private sector will help in developing PPP
mechanisms for enhancing access for early and safe abortion services.
□
NRHM proposes to optimally use services of a large pool of the diverse range of RMPs who
practice in rural areas and urban slums. District planning teams may get a full picture through HH
surveys. Capacity building programmes should be developed after taking in to cognizance their
core competencies and also which health care needs cab be serviced through these practitioners
The information collected can be used for forging linkages with the private sectpj^ Depending on the
motivation of the private provider to be a partner in the PPP mechanism, appropriate strategies and
interventions could be planned on the basis of facilities and expertise of the institution. During the
district/block level consultations, there is a need to invite the private practitioners or heads of private
institutions and for this purpose the help of local IMA /FOGSI /IAP /other associations of private doctors
could be sought.
3.9 ICDS Programme - Template 9
This is one of the most critical programmes from the convergence viewpoints. The complementary nature of
job functions of ICDS worker at the village level with that of the ASHA/ANM strongly vouch for convergence
of services and assures better accessibility to health care servicq^/Given this backdrop, information about
the programme in terms of coverage, human resources will have to be collected.
Details of ICDS programme-Template 9
Name of
the block
with ICDS
Programme
Number of
AWCs
S
F
CDPOs and
ACDPOs
S
IP
Supervisors
S
IP
AWWs
S
IP
AW helpers
S
IP
_1_
2
3
4
5
6
7
8
9
10
Total______ ______ ______ ______ _______
S=Sanctioned; F=Functional; and IP=ln Position
50
When district and block level consultation meetings are planned, it is important to ensure the presence
of ICDS functionaries. Joint monitoring meetings at sector or block level could be considered^ '
District Women and Child development officer will be in position to provide information on the
functional AWCs, AWWs/helpers, Lady Supervisors and CDPOs in the district. It will be useful to know
if there are more vacancies in the tribal blocks or in the sectors, which are in remote areas: Presence
of any training institution for AWWs in the district will help in implementing capacity development
programmes not only for AWWs but may be for ASHAs and other community based health resources.
It will be also useful to assess range of convergence activities with health sector in the district. Joint
training of peripheral service providers, organisation of health day at AWCs with participation from
Health functionaries, referral of severely malnourished children to health facilities are such activities.
4.10 Elected Representatives of PRIs - Template 10
The NRHM has placed strong emphasis in addressing local issues and solutions and making it community
centric through the involvement of PRI’s. In the process, the responsibility of preparing village health plans
has been entrusted to the village health committee of the Gram Panchayats, It is therefore, necessary to
get their views endorsed not only/fi the formulation process but also in implementation and monitoring of
the programme, information on the following will have to be collected:
Elected representatives to Panchayat institutions-Template 10
Name of the
block
Total
panchayat
villages
Total ZP
members
Male
Female
Total BDC/Mandal
members
Female
Male
Total Panchayat
Pradhans
Female
Male
1
2
3
4
5
6
7
8
9
10
Total
The District Panchayat chief heads District Health Missions. NRHM implementation manual envisages
thapPRIs should have greater say in management of NRHM/Snd this, will set out a process of
communitization. Information from this matrixp/vill help to plan capacity development interventions for
PRIs and also help the planning team to design local area -specific interventions with PRIs/
zKurthermore, it is possible to expend some earmarked resources at the level of PRIs./
3.11 NGOs & CBOs - Template 11
In the RCH programmes, mother and field NGOs are supported to organise service delivery activities in the
district. The important role of non-governmental and community based organizations in community
mobilization and ensuring their involvement is a proven testimony. NRHM strongly advocates their
^.. involvement and ownership, as essential pre-requisites for achieving the best results. Listing and locating
51
P
lUld3
such
such resources
resources in
in the
the district
district could
could be
be useful.
useful. Appropriate
Appropriate linkages
linkages can be planned and implemented
through these agencies and carrying out demand-generation activities can be thought off.
NGOs & CBOs - Template 11
Names of NGOs
Key Activities in
Health/Nutrition/community
organisation
Block/Villages of NGOs operations
In many districts MNGOs and FNGOs are already working under RCH programme. There may be
other NGOs actively working in areas of water and sanitation, nutrition etc. The District planning team
may review these data for enhancing service access in under covered blocks/ sectors or even cluster
of villages or working on the demand side.
3.12 Analysis of Key Health Indicators
In this section an overview of health and reproductive and child health status of the district will have to be
presented /The district level household survey (DLHS) supported by Government of India has covered
most of the reproductive and child health indicators and^he results for the 2002-03 round is available This
data has to be analyzed by comparing urban and rural areas, SC/ST and others, gender and by SLI. By
doing so, one gets an idea of the utilization pattern among the different categories and will provide
necessary inputs as to what needs to be done to enhance services. Besides this analysis, the service
statistics data on health programmes have to be analyzed. Common diseases in the area, endemic
pockets, and seasonality of diseases will have to be compiled. Blocks that have reported more number of
cases of communicable and non-communicable diseases will have to be identified.
Refer steps detailed in Box for interpretation of DLHS data.
•
Box 1
Analyze the trends In above indicators by selected background characteristics (urban/rural,
•
•
SC/ST/others, gender and by SLI
Compare with the state average and the best performing district in the state
Draw inferences on the basis of the analysis
The above analysis Should lead to identification of issues in terms of access, quality and demand^
Further, examine the block-wise utilization of maternal health services to see variations through service
statistics reports. This information will be further useful for conducting block level consultations.
•
•
•
•
Identify blocks with poor or inadequate utilization and reasons there of.
Also, look at utilization data by BPL and SC/ST category
Summarize the reasons of poor utilization
Identify the reasons and make a note such as staff vacancies
52
3.13 Maternal Health-Template 12
This template will give an overview of the utilization pattern of maternal health services in the district
specifically by comparing urban and rural areas, SC/ST and others and by SLI. By analyzing trends
from survey data, one gets an idea of changes in the utilization pattern over the reference period and
what needs to be done to enhance the services/ In here, we have restricted to just four indicators that
pertain to utilization pattern, quality in terms'of adherence to complete package of antenatal care
services and complicated deliveries.
Examine the performance on the following indicators of:
1.
2.
3.
4.
5.
6.
7.
8.
Percent of pregnant women who availed complete package of ANC services
Percentage of institutional deliveries
Percentage of safe deliveries
Percentage of C-section deliveries
Percentage of Maternal deaths audited
Maternal mortality
Maternal death audiLesp.
verbal autopsies
Note: Follow steps listed in Box 1
3.14 Family Planning - Template 13
An overview of the current use of modern contraceptives in the district will have to be synthesized in
this template. Only one indicator on current use by methods has been considered while the other is on
unmet need for family planning. The unmet need for family planning will help us in estimating the
potential users who need to be identified, counseled and provided services of their choice.- While
analyzing these indicators, also look into the reasons for discontinuation or non-use among current
non-users and highlight the major findings.
Examine the performance on the following family planning indicators of:
Summarize the salient findings in bulleted form by urban/rural & SC/ST
Limiting
NSV / Conv. Vasectomies
Minilep
Laparoscopic Sterilization
Spacing
IUD
OC
CC
□ Contraceptive use by methods
□ Unmet need by limiting and spacing
□
□
□
% of sub district hospitals / CHCs / Block PHCs providing Sterilization services
% CHCs / PHCs / Sub Centres providing IUD insertions
Number of facilities providing NSV services on fixed day
Sterilization failures / any deaths / complications requiring hospitalization (Use data from District Quality
Assurance committee)
Implementation of National FP insurance scheme in the district
% of deaths / failures / complications compensated
Quality care monitoring
% of deaths / complication requiring hospitalization / failures monitored by Quality Assurance Committee
■53
Also review contraceptive use in terms of state performance and for the best performing district from the
RHS state reports.- Rank your district in light of this information and laterzdnalyze block-wise data on
sterilization from service statistics and identify good and low performing blocks, +md out reasons; this may
be,Attributable to less number of certified providers for
sterilization services or non-availability of
contraceptive supplies/
/ The data for unmet need for limiting and spacing should be reviewed and also analyzed in with reference to
Standard of Living Index (SLI). If unmet need for spacing is higher than state average, then draw your
inferences and think of designing interventions to enhance access through alternate service delivery
channels.
' Any failures due to sterilization, deaths and major complications (requiring hospitalization) should be
reviewed. If there are too many failures occurring in a particular block, then reasons in terms of skills of
surgeons providing sterilization services and quality issues will have to be looked into and proper capacity
building interventions will have to be planned.
3.15 Child Health - Template 14
The status of child health has to be summarized in the template. The indicators of child health relate
to the immunization status of children (12-23 months), details pertaining o exclusive breastfeed ng
prevalence of diarrhea and ARI and more importantly their nutritional status in terms of grade lll/IV
malnutrition. These indicators together will provide an essence of child heakh status in the district
While analyzing immunization status, also observe the dropout rate between doses and children who
' haven't received any dose of the vaccine^rom the programme perspective, ft js important to know
Xhe percentage of children who have not deceived any childhood vaccine at all. .Further, it is necessary
■ to understand the breastfeeding practices in the community and depending on tha■ n®cessary
behavioural change strategy will have to be devised at the time of formulating the action plan.
Examine the following child health indicators of.
54
Examine the performance on the following child health indicators of:
Summarise the salient findings in bulleted form by urban/rural & SC/ST
□
□
□
□
□
□
□
□
Full Immunization coverage rate (12-23 months)
1BCG-Measles drop out rates (should be less than or equal
. to 15 percent), DPTi to DPT3
Percentage of planned immunization sessions held
Initiation of breast-feeding
o Collustrum
o Exclusive breast-feeding
Incidence of grade III/IV malnutrition (collect from ICDS)
Vitamin A coverage with two mega doses each year of children in 9-36 months
Prevalence of ARI
o Treatment seeking behaviour
Prevalence of Diarrhoea
o Treatment seeking behaviour
o ORS use
It would be useful to/^can the proportion of planned immunization sessions being held in the blocks
and sector PHCs. If less than 80% sessions are being held in a particular area than this needs
additional inputs for providing immunization services.
Proportion of newborn children being initiated with colostrums feeding within half an hour of birth
needs to be reviewed. You may also like to get the information from the in-charges of major hospitals
in the district regarding when breastfeeding is initiated in cases of institutional deliveries. Similarly data
on prevalence of exclusive breastfeeding should be reviewed and any variations across blocks (if
possible), socio cultural groups should be acknowledged. This would help in designing appropriate
BCC interventions.
ICDS MIS is an important source for magnitude of malnutrition in below 6 yrs. Identify if there are
blocks with high levels of severe grades of malnutrition. In block level meetings planning team may
probe about the reasons for high prevalence, referrals to PHCs and guidelines being followed for the
management of severe grades of malnutrition.
With reference to Vitamin A it will be useful to assess availability of supplies round the year, coverage
with two rounds in the year and analyzing coverage with respect to SC/ST and gender parameters. /
55
3.16 RNTCP, NVBDCP, NPCB, IDSP, NLEP & NIDDCP - Template 15
Information on/hese two diseases will have to be compiled along with other programmes under
consideration/ Until now, the planning for national health programmes has remained vertical.
However, as part of National Rural Health Mission (NRHM), efforts will have to be made to evolve a
bottom-up and an integrated planning process. Unlike RCH indicators, survey data on health is not
available and hence will have to be compiled from district service statistics. The national monitoring of
malaria and tuberculosis has confined to a few critical indicators that are compiled from the distnc:level Information on these indicators will have to be .put together and along with it, other health
problems in the area will have to be stated block-wise and presented in Template 15. In the remarks
column, specify seasonality and endemic pockets that may need attention during plan formulation,
disaggregated data is available then it can be useful.
The information on malaria indicators should be available with, the AMO (person responsible for
malaria programme in the district). This information needs to be reviewed in the light of the state API,
plasmodium Falciparum rate, and any deaths due to malaria or resistance to Chloroquine. It would
also be useful to review the slide positivity rates (total and parasite specific) as per blocks as the
distribution of parasite may vary in blocks.
56
Examine the performance on the following indicators of:
Summarize the salient findings in bulleted form by urban/rural & SC/ST, Male/Female
□
□
□
□
Collect information on API for Malaria
o Endemic pockets
Slide Postivity Rate and Plasmodium Falciparum Rate (PFR)
Annual Blood examination Rate
Number of Fever Treatment depots and DDCs
Collect information for the TB programme
Percentage ofTB suspects examined out of the total outpatients
Annualized New Smear Positive (NSP) case detection rate per 100,000 population
o It is the no. of new smear positive tuberculosis cases registered for treatment in a year per lakh population. In
India, the estimated incidence of NSP cases is 75 per 100,000 population per year. The national goal is to detect
at least 70% of the estimated cases, such as, 53 NSP cases per 100,000 population per year.
□ Annualized Total Case detection rate per 100,000 population
o It is the number of total TB cases (new and re-treatment) registered for treatment per 100,000 population per
year.
□ Treatment success rate
Percentage of new smear positive patients who are documented to be cured or to have completed successfully
o
treatment. The global and national goal is to achieve and maintain atlcast 85% treatment success rate among the
new smear positive cases registered for treatment. This indicator is reported 13-15 months after patients are
registered for treatment.
□
□
Collect information for National Programme for Control of Blindness
□ Cataract Surgery Rate (CSR): Targeted CSR is up to 450/100,000 population over 3 years
Analyze data for gender (ensure more that 50% coverage in women)
O
O
SC/ST
o Economic criteria (at least 60% people living below the poverty line)
o At least 80% of the surgeries should be having IOL
□ All School children in the age group of 10-14 years should be screened for refractive errors
o Percentage of children detected with refractive error should be 5-7%
□ Also identify number of screening camps organised last year, personnel trained, service deliver}'- points having quality
assurance guidelines, percentage of teacher’s trained, number of NGOs receiving assistance and beneficiary assessments.
Collect information for National Leprosy Eradication Programme
□ PR - Leprosy cases per 10,000 population
□ ANCDR - New leprosy cases per 1,00,000 population
□
□
Proportion of MB, Female, Child, ST, SC cases among the new cases among the new cases detected
Proportion of Patients completed treatment (RFT}
Collect Information about activities undertaken for IDSP in the district
□ Percentage of facilities sending their reports in time
□ Up gradation of labs
□ Training of staff in disease surveillance
Collect Information about activities undertaken for IDD in the district
□ No. of persons suffering from ID D
□ Number of persons consuming lodated salt
57
The district tuberculosis officer who is also reporting person for RNTCP should be in the position to
provide information on the key performance indicators for the programme. If the district is lagging
behind with the state averages then the planning team should assess the reasons and what all needs
to be done to improve the programme performance.
Similarly Information on the performance indicators of NPBC and NLEP should be obtained from the
respective programme officers in the district.
The list should include District Malaria Officer (DMO) and not AMO as the person responsible for
implementation of Vector Borne Disease Control Programme in the district.
3.17 Locally endemic diseases in the district - Template 16
Locally endemic diseases in the district
Names of locally endemic diseases such as JE,
chikengunya, filariasis, endemic goitre, kala azar,
endemic flourosis or other occupational diseases
Chemical contamination of water sources or other
zoonotic diseases such as Anthrax etc
Names of affected Blocks
/in some districts there may be endemic health problems and DHAP should reflect on the strategies to
respond to these problems. The information could be obtained from the hospital MIS or through
surveys/ research. Any research reports available should also be reviewed. The distribution of the
diseases as per blocks or cluster of villages (in cases of chemical contamination of water sources)
should be mapped.
3.18 New interventions under NRHM - Template 17
NRHM activities are being implemented in the districts since 2005-06. It will help the planning team to
review performance with respect to certain key activities.
This is not an exhaustive list of the activities which district may have undertaken during the last year
under NRHM. Opportunity should be taken to analyze the reasons for low performance such as in
case of ASHAs, or disbursements for JSYs or registration of RKS etc.
58
Activity
1.
2.
Number of ASHAs selected________________________
Number of ASHAs undergone First Orientation training for
seven days
3.
No of Fully trained Accredited Social Health Activist (ASHA)
for every lOOOpopulation/large isolated habitations.
4.
Number of clients benefited under JSY
5.
No of Village Health and Sanitation Committee constituted and
untied grants provided to them.___________________ _____
No of 2 ANM Sub Health Centres strengthened/established to
provide service guarantees as per IPHS,
6.
4
No of PHCs strengthened/established with 3 Staff Nurses to
provide service guarantees as per IPHS.
5
No of OHGs strengthened/established with 7 Specialists and 9
Staff Nurses to provide service guarantees as per IPHS.
6
No of Sub Divisional Hospitals strengthened to provide quality
health services.
7
No of District Hospitals strengthened to provide quality health
services.
8
No of Rogi Kalyan Samitis/Hospital Development Committees
established in all CHCs/Sub Divisional Hospitals/ District
Hospitals._________________________________________
No of Untied grants provided to each Village Health and
Sanitation Committee, Sub Centre, PHC, CHC to promote local
health action.___________________________ ___________
Annual maintenance grant provided to every Sub Centre, PHC,
CHC and one time support to RKSs at Sub Divisional/ District
Hospitals.
10
11
12
Systems of community monitoring put in place.
13
Procurement and logistics streamlined to ensure availability of
drugs and medicines at Sub Centres/PHCs/ CHCs.
14
No PHCs/CHCs/Sub Divisional Hospitals/ fully equipped to
develop intra health sector convergence, coordination and
service guarantees for family welfare, vector borne disease
programmes, TB, HIV/AIDS, leprosy etc._________________
District Health Plan reflects the convergence with wider
determinants of health like drinking water, sanitation, women’s
empowerment, child development, adolescents, school
education, female literacy, etc._________________________
Facility and household surveys carried out or not
15
16
17
Annual State and District specific Public Report on Health
published
18
Institution-wise assessment of performance against assured
service guarantees carried out.
19
Mobile Medical Units provided
20
21
No. of Ayush dispensaries re-located to PHCs
No. of PHCs where AYUSH physicians appointed
Goal for District
Achievement %
59
1'
5
5.1 Block Level and Stakeholders Consultations
Towards ensuring that the district health action plans (DHAPs) represent the voices on the abound and
address community’s needs in the area of holistic health care, it is proposed to hold b ock level
consultations in each block of the concerned district/National Rural Health Mission (NRHM) places
emphasis on community participation and need-based service delivery with an improved outreach to
disadvantaged communities. In keeping with this focus, the outcome of the block level consultations
will be a vital part of the information to guide district plans. The information brought forth from the
village to the Gram Panchayats (GPs) and subsequently presented atthe block level consultation is
not expected to be comprehensive but should be indicative enougj/to help prioritize activities and
budgets of different sectors which will be included in the overall district plan.
There are several enabling ingredients in the policies, plans of the state, districts, the health and family
welfare programs under NRHM. The trick is to identify the enablers, the opportunities and use them to
turn around existing constraints and problems. Block level consultation is one such opportunity that
can help the community and the service providers jointly identify the ways in which they can plan to
effectively meet their needs under NRHM.
5.2 Why undertak^block level consultation^ to prepare a district action plan?
Objectives:
•
•
•
•
To actively engage a wide range of stakeholders from the community, including the
panchayats, in the planning process
To identify local issues and concerns as well as vulnerable groups and areas to reach
consensus on feasible solutions/intervention strategies
To take advantage of opportunities for inter sectoral convergence that exist at the block level in
making the planning process more holistic in nature
To identify priorities at the grassroots and carve out roles and responsibilities at the panchayat
and block levels in design and implementation of DHAPs for greater ownership and need
based implementation of NRHM
It is expected that the district planning process will harmonise the information received through the
different block level consultations tojtlentify sectoral and geographical priorities and accordingly
request line departments to undertake activities on priority basis in the identified panchayats. Specific
health related information that emerges from the block level consultation could be utilised by the
Medical Officer/s as a part of thp^facility planning process. The health information that is outside
his/her purview will be taken up for discussion at the district consultation with the presence of
CMHO/RCHO for prioritization by the health department.
60
5.3 What is the approximate timeframe to prepare for and hold block level consultations? Who
will facilitate the entire process?
The district level planning team should engage a designated facilitating agency or the MNGO/FNGO to
facilitate the process so thapthe consultations can be completed in an efficient and timely manner. If
, an NGO or MNGO/FNGO is not available for a given block/s an external agency from the district or
from the neighbouring district can be identified. The following generic criteria should be kept in mind
while identifying the agency:
■
■
-
Involved with the development/social sector
Familiar with health issues, government programmes and schemes and has an understanding of
the field/community
Has staff (both men and women) with analysis and documentation skills required to facilitate the
process and to deliver in a timely manner
The timeframe is likely to be about a month and a half for the full process. The preparatory processes
can be started simultaneously and should take about a month. The next 15 days should be used to
hold the actual consultations in each block of the district, set priorities and finalise outcome of the
consultation for each block. This kind of planning will allow the district planning team to participate in
consultations in all blocks.
The district planning team will have to decide the steps it will like to follow to engage with the
panchayats and the community, based on which the time taken may vary from district to district.
However, on an average any given district should not take more than 45 days to complete the process.
It is a novel idea to involve MNGO/FNGO or an external agency for facilitating block level consultation.
However, the issues of sustainability uniformity, contents and the quality of the outcome need to be looked
into. It would be more appropriate if the district health plan is empowered to carry out such consultations by
involving MNGO/FNGO.
61
5.4 What preparatory processes need to be undertaken before holding the consultation?
Step I
An administrative block is likely to consist of about 30-40 gram panchayats. While the block level
consultation will involve the Sarpanches from these panchayats, it wi" 'be necessary tha the
information they provide capture the situation and the needs on the ground. The MNGOs/FNGOs
already involved under ROH 2 should be made a part of this process. To facilitate this process, the
concerned facilitating agency/ NGO/ consultant needs to hold a one-day orientation of the gram
panchayat representatives (at least two from each GP) and share an indicative checklist on the basis
of which information on health concerns can be collected and subsequently shared at the block leve^
consultation./the checklist does not aim to collect household level data on health indicators. DLHS
data may be referred to give a general sense of the district and further supplemented with facdity level
service data if possible./The checklist is aimed at understanding the access, demand and quality
related concerns in accessing health services and priorities of the GP to address these concerns.
(Refer to the checklist 1).
On the service side, the medical officers can be requested taring to the block level consultation
information on health resources available in the block. This could include information on health
facilities- qovt and others ayurveda/ homeopathy/ unani dispensary, private nursing homes and
clinics, government and private sector testing laboratories, essential staff, equipment and supplies and
infrastructure. The gaps in resources should be highlighted at the consultation.
To summarize Step I,
•
•
•
•
•
Involve MNGOs/FNGOs in the process of holding block level consultations
Orient Gram panchayat representatives on the process and collection of village/ GP level
information prior to the consultation
Share and explain the use of the indicative checklist to collect GP level information. Remember
that the checklist is only indicative and should be modified based on assessment at the field
level as to the kind of information that will be useful and easily available.
Service side information to be collected and gaps identified by the medical officers
If possible, complement the information collected from the GPs with block/sub-centre level
service data available at the facilities
62
Step II
The NGO/ facilitating agency will consolidate the information received from the different gram
panchayats and if possible, organise a one-day meeting for the validation of information received and
filling of information gaps if any. The discussions will also be aimed at each gram panchayat arriving
at the priority areas that it would like to address under NRHM.
If the one-day meeting to validate information is not possible, then discussion on priority setting should
be held during the consultation where both the panchayat members and the health staff will place on
the table their priorities. The NGO/facilitating agency will consolidate the information collected from GP
and circulate a brief note providing a consolidated picture during the consultation. (Format for
preparing the brief note based on an analysis of access, quality and demand side concerns is at
checklist?).
To summarize, Step II
• Following the collection of GP level information, the facilitating agency/NGO to hold a meeting
to validate the information (optional, to be held only if possible)
• Facilitating agency/NGO to consolidate the information collected and prepare note for
circulation based on the indicative format at checklist 2. Service side information should be
taken from the concerned medical officers.
• The panchayats and the service providers to undertake priority setting during the consultation
based on the consolidated picture presented by the facilitating agency/NGO
5.5 Who will participate in the block level consultation?
It will be useful to include people from diverse sectors to bring in a range of perspectives - each from
his/her own lens. The team players will be:
Sarpanches from the Panchayats
Pradhan of the Panchayat Samiti
Representatives from the district planning team
Child Development Project Officer, ICDS
Block Development Officer
Block Medical Officer and health service providers
Education extension officer
Other community representatives
Representatives of local NGOs/CBOs
Other line department officials linked with NRHM functioning at the block level
It would also be important to include some very important stakeholders in the process of block
planning
- Service Associations of the Health Staff existing .E,g ANMs Association, Anganwadi Association
etc
■ Occupational Groups like fishermen , miners etc
■ Representatives of the disadvantaged groups esp women and the disabled
U Ml
0 u
63
1
What methodology will be followed for holding the actual consultation?
The consultation should be chaired by the Chairperson of the Block mission - the Pradhan of the
panchayat Samiti and may be co-chaired by the BDO and the MO, Block PHC/CHC.
Suggested Agenda for the Consultation
■ Objectives of the consultation (district planning team)
■ Briefing on the preparatory process followed (facilitating agency/NGO/consultant)
- Outcome of the information collected and analysed from community and service providers
(facilitating agency/NGO/consultant)
- Discussion and highlights of the service gaps and concerns of the service providers (MOs/ frontline
functionaries/others)
■ Discussion on the community concerns and priorities (sarpanches/woman representatives/
NGO/Asha /ANM/Anganwadi worker)
- Agreeing on key problems and solutions and presentation of the matrix to the district planning
team (facilitating agency/NGO/consultant)
64
Step I: Problem Identification
The general process of the consultation should include a sharing of health priorities by each Sarpanch
based on his/her interactions in the GP and the information collected. Information will also be shared
by the NGO on the outcome of the discussions held with the women’s groups and their concerns. This
will be followed by a presentation from the NGO/ facilitating agency on the overall picture emerging
from the information collected through the checklist and that provided by MO/service providers. Based
on discussion on both demand and supply side concerns in the block, the priorities should be set and
agreed. Following indicative format may be used for the purpose identifying the problems,
corresponding solutions.
Indicative example of a problem - solution matrix,
Main Causal factor/s
Solutions
Primary Role
E.g. Poor maternal
health
Distance, connectivity,
home deliveries, costs
involved
Possibility of strengthening ANM
skills,
input on
skilled
birth
attendance, training of TBA, role of
Asha in accessing JSY for transport
and institutional delivery
Health department
Panchayats
SHGs
E.g. High incidence of
malaria
Delayed identification
of
cases,
limited
access to medicated
bed
nets,
limited
elimination
of
breeding
sites
for
mosquitoes
Improved service
early detection
E.g. Minimal no. of
functional and safe
ANM quarters
Lack of running water
and safety, located
away from habitation
Making the residential quarters
functional - use of untied funds,
addressing grievances of the ANM,
taking safety measures. Taking
innovative measures such
as
ensuring that the ANM stays at
least 2-3 times each month till the
problems are completely sorted out.
Providing information to community
of her availability and ensuring her
safety on these days
Panchayats/NRHM
CBOs
E.g. Limited ANC
coverage and lack of
community ownership
of the outreach
services and its
monitoring
Women and children
from
remote/tribal
hamlets not included,
lack of awareness
about services to be
expected
during
outreach
sessions
Executing demand-side strategies building
awareness
among
panchayats and SHGs on services
to be expected through outreach,
ward panches take responsibility for
supervising outreach sessions and
monitor time spent by the ANM, to
ensure involvement of Asha and
AWW, panchayat to identify and
ensure
better
coverage
of
unreached areas, joint orientation of
Health
department/NRHM
Panchayats /SHGs
Women and child
development
department
Problem
(urine
exam
during
ANC, taking weight,
use
of
autodisenabling syringe),
outreach
and
Health department
Water and Sanitation
Panchayats
65
Problem
Main Causal factor/s
Solutions
limited home visits by
ANM,
lack
of
coordination between
AWW, ANM and Asha
GP, AWW, ANM and Asha under
NRHM
Primary Role
E.g. Staff vacancies ANMs and medical
officers
Transfers,
filled yet,
absence
post not
leave of
Expediting filling of posts, recruiting
contractual
ANM/s,
exploring
options for partnership with private
sectors, organising PHC level
camps with wide publicity
Health department
E.g. Greater stock
outs during
rains/landslides as
facilities become
inaccessible
Limited
systematic
planning of demand
for drugs based on
seasonal
illnesses
and
inaccessibility
during certain periods
Requesting stocks on priority while
anticipating gaps in supply during
specific periods, improved planning
to address seasonality of health
care seeking behaviour and pattern
of illness,
Close monitoring of incidents of
stock-outs and corrective action
taken,
identifying
alternative
sources of supply - social
marketing options
Health department
E.g. Poor coverage
for immunisation
amongst children,
especially girls from
BPL families
Lack of information,
limited
access
to
provider
services,
limited
attitudes,
to
outreach
fringe/remote areas
Close monitoring by ANMs, greater
coordination between Ashas and
Anganwadi workers, involvement of
ward
panchs and
SHGs
in
identifying critical households and
ensuring service, involvement of
local informal / caste leaders to help
in breaking myths, providing service
information and ensuring coverage.
Health department,
Women and Child
Development
department,
panchayats, SHGs,
leaders
informal
I
through CBOs
Other critical areas of priority could include improving ANC coverage, reduction in home deliveries,
improving outreach to remote areas - especially in case of immunisation and nutrition, addressing
specific problems of women, etc.
What will be the outcome of this block level process? How will it contribute to the district plan?
The facilitating agency/NGO will prepare a detailed report of the consultation and forward it to the
district planning team. The report will consist of general details of the discussion and agreed priorities
-both service side and community side included. The information collected from the GPs and the
women’s groups will be annexed to the report.
The district planning team can use the information received from each block level consultation to
prioritize activities and resources as a part of the district health action plan. It will also be useful in
identifying vulnerable pockets and isolated areas requiring greater attention. The priorities arrived at
through the block level consultation will also concern sectors such as sanitation, drinking water,
66
women and child development. Therefore, the block level report will also help steer discussions during
the district consultation on inter-sectoral priorities and budget allocations by other line departments.
To summarize, through the block level consultation information will be available on
Community level health concerns, specifically those of women and vulnerable groups
Concerns of the providers and service gaps as identified by the functionaries at the block level
Geographical areas/panchayats requiring greater focus and attention
Possible roles that need to be played by the panchayats and community groups such as the
self-help groups
5. Areas for inter-sectoral dialogue, coordination, budget and activity planning
1.
2.
3.
4.
67
Checklist 1
For collecting information at the Gram Panchayat level
A.
Status of households
Name of the GP:
Total no. of villages under the GP:
Approx, total population/total no. of households
Average households per village in the GP:
Total no. of hamlets (specifically mention tribal hamlets if any)
Total no. of BPL households
Total no. of households that own agricultural land
Total no. of households involved in wage labour more than 6 months a year
Total no. of women headed households (widows or families where male members have migrated)
Total no. of births registered in 2005:
No. of boys No. of girls -
B.
Information on resources
No. of villages not connected by motorable road:
Average distance of villages from the nearest Primary Health Centre (PHC)
Average no. of tube wells/ handpumps/piped water supply per village
Approx, no. of households with functional toilets
No. of functional ANM residential quarter/s
No. of functional sub-centre/s with ANM
No. of functional Anganwadi centres with Anganwadi worker and helper
No. of villages connected with electricity and /or telephone connectivity
No. of private medical practitioners in the GP
No. of Registered Medical Practitioners in the GP
No. of trained Traditional birth attendants in the GP
C.
Information to be collected through the Village Health Committee
Average household health related annual expenditure
In general, the type of illness/ health condition where private healthcare is availed
In general, the type of illness/health condition where public healthcare is availed
Average no. of times that money is borrowed to meet health expenses
Average amount borrowed
Proportion of home deliveries to total deliveries
No. ANM outreach sessions held in the last 3 months
No. of health drives undertaken in last six months - chlorination of wells, toilets built under TLC,
distribution of medicated bednets, mop-up immunisation drives, ORS distribution, drives to ensure
—
68
D.
Information to be collected during women’s group meeting at the gram panchayat level
(The meeting can be facilitated by an NGO/Asha or Sahyogini/women’s development worker and
should involve at least 2 women’s group representatives from each village)
Separately mention for each, what are the common health problems faced by women, men and
children?
Where do you go in case of a health problem? Sub-centre, PHC, to a private provider or a local village
person or Dai/TBA or use home remedies
In your perception, what is the reason for a majority of health problems? Water, sanitation, lack of
food, lack of services or bad quality services or lack of awareness and knowledge, etc.
If you had to improve the health status of your village what would be your priorities - access to safe
drinking water, better sanitation and access to toilets, improved access to public facilitates or access to
financial resources to avail healthcare or access to a health worker closer to home, etc. Specifically
highlight two most important priorities for the group.
What is your perception of the
What are your expectations from the panchayat to improve the status of health in your village?
69
Checklist 2
Format for the consolidated picture emerging from the GP level information
To start with, summarise general information on status of households and resources in Gram
panchayats
(i)
An analysis of BPL households and vulnerable households- on an average per gram
panchayat state the number of households that require close monitoring by the panchayat
and service departments to improve access and quality to services (this number will include
household information collected from points A. 6, 7, 8, 9 of the checklist)
(ii)
An analysis of bottom five GPs with lowest numbers of girls to boys born in 2005 - requiring
health department intervention in implementing Act against sex selection, closer monitoring
on misuse of ultrasound, monitoring of birth registration of panchayats, community monitoring
to ensure early registration and tracking of pregnancy until delivery with the help of Asha and
AWW (point A. 10)
(iii)
J GPs with
..Lj no ANMs/ non-functional sub-centres or non-functional ANM quarters No. of
requiring intervention from panchayat and health department/NRHM (point B.5, 6)
(iv)
No. of villages requiring anganwadis/ Anganwadi worker or helper (point B.7)
(v)
No. of GPs where TBAs require stipulated training on recognising emergency signs,
information on referrals and safe delivery kits (point B. 11)
(vi)
No. of GPs showing in general a high utilisation of private sector services irrespective of the
seriousness of the illness - this information should be seen in the context of which GPs are
also showing larger no. of times that money is borrowed to meet health expenditure. The
analysis should signal improved service outreach to vulnerable populations who are
accessing private sector services through borrowed resources (point C. 2, 3)
■
Area-wise division of areas in the block with greater no. of home deliveries (point C. 8)
■
GPs with no outreach session held in last three months (point C. 9)
■
GPs with no health drives initiated in last six months (point C. 10)
■
Concerns of women (point D.)
a.
b.
c.
d.
Mention the health facility/ provider most frequented by women
List the most common health priorities highlighted by women
List the general expectations of women from panchayats with regard to health
GPs with no AYUSH infrastructure
70
CF^ta-
6
Setting Objectives of the DHAP
The District Planning team entrusted with the task of formulating DHAP should take into account the state
NRHM PIP and the Memorandum of Understanding between the state and the national government. In line
with the state goals, the district should make an attempt to complete the following matrix, which is
illustrative.
The inputs for this matrix will largely come from the situational analysis conducted (as indicated earlier in the
chapter 4) and the block-level consultations should guide you in deciding what a district can achieve
pragmatically, in the given time frame. This apart, block level consultation will also enable in identifying the
geographical distribution of the interventions and what blocks/ cluster of village’s needs special attention for
achieving certain outcomes. Additionally, problems such as adverse sex ratio (based on census data) or
endemic health problems have to be factored in.
The NRHM implementation framework makes a strong reference to achieve outcomes for the defined
outlays and allocations. Hence it is critical to provide quantified outcomes that are clearly measurable in the
district context, without spending too many resources on means of verification. Following matrix lists
quantifiable objectives, which may be considered by the District planning teams.
Objectives to be Achieved by the district
1.
2.
3.
4.
5.
6.
7.
8.
9.
Universal coverage of all pregnant women with package of
quality ANC services as per national guidelines__________
Increase in deliveries with skilled attendance at birth
including institutional deliveries_____________________
FRUs (including DHs, CHCs/PHCs) made functional as
defined in the National RCH 2 PIP___________________
Universal coverage of all eligible pregnant women under JSY
scheme_____________________________________
Increase in percentage of new born babies given colostrums
Increase in prevalence of exclusive breast feeding________
Increase in percentage of fully protected children in 12-23
months as per national immunization schedule__________
Universal coverage with Vitamin A prophylaxis in 9-36
months children________________________________
Percentage of severely malnourished children below 6 yrs
referred to medical institutions
Current levels
i.e baseline
(give data
sources if
possible)
DLHS, 2003-04
Levels to be
achieved in 0708
Levels to be
achieved in
08-09
MIS & Surveys
MIS
MIS
Survey
Survey
Survey
MIS & Survey
ICDS MIS
71
Current levels
i.e baseline
(give data
sources if
possible)
Survey
Objectives to be Achieved by the district
10. Unmet demand for contraception
-Spacing
-Limiting
A. Number of Govt. Health Institutions providing:
Levels to be
achieved in 0708
Levels to be
achieved in
08-09
DH/SDH/CHC/PHC
i) Female sterilization service;
ii) Male sterilization services
iii) IUD insertion services------- CMC/PHC/SC
B. Number of accredited private institutions providing:
i) Female sterilization services
ii) Male sterilization services
iii) IUD insertion services
11. Number of health institutions in PHCs/CHCs offering ARSH
services
___________ _______ __ _________
12. Number of health institutions providing services for
management of STIs and RTIs_____________ ________
13. Performance indicator for NVBDCP
-API for MP
-Annual blood examination rate for MP increased (over 10 /o of
all OPD cases)
-Slide Postivity Rate
-Number of deaths due to malaria
14. Performance indicator for RNTCP
-Percentage of TB suspects examined out of the total outpatients
-Annualized New Smear Positive (NSP) case detection rate per
100,000 populations
-Annualized Total Case detection rate per 100,000 populations
-Treatment success rate_______________ ___ _____ — ----15. Percentage (as planned) of ASHAs functional in the district
(received induction training )
________ 16. Number of RKS registered /established
MIS
MIS
MIS
MIS
MIS
MIS
District
reports/FMIS
District
report/FMIS
17. Number of Health care delivery institutions upgraded
- SHCs
PHCs
- CHCs to FRUs fulfilling the 4 basic criteria in FRU guidelines
Upgrading to IPHS will come later
(these institutions should be in conformity with IPHS)_________
District
18. Village health and sanitation committees Constituted
report/FMIS
Grants given_________________________
_ _________
Partly from
19. Number of SCs strengthened
MIS/District
- Additional ANMs hired
financial
reports
- Annual maintenance grants given
___________ __
District
20. Number of PHCs strengthened to provide 24x7
reports/FMIS
3 staff Nurses hired
-
Annual maintenance grants given
______
72
Objectives to be Achieved by the district
21. National Blindness Control Programme
- Cataract surgery rate (450/100,000 population)
-% surgery with IOL
- School Eye Screening in the age group of 10-14 years should
be screened for refractive errors
- Oral Health Screening for:
Community
School Children_____________________________________
22. National Leprosy Eradication Programme
- PR - Leprosy cases per 10,000 population
- ANCDR - New leprosy cases per 1,00,000 population
- Proportion of MB, Female, Child, ST, SC cases among the
new cases detected
- Proportion of Patients completed treatment (RFT)________
23. Integrated Disease Surveillance programme
- Number of labs to be upgraded ( L1 and L2)
- Number of staff to be trained in surveillance activities
24. Staff for mobile medical units in place
25. __________________________________________
26. Number of facilities to be covered for facility survey
- SHCs
- PHCs
- CHCs______________________________________
27. Number of Villages to be covered for HH survey
28. Number of Community hearings planned______ _
29. District Training plan developed and implemented
30. District BCC plan developed and implemented_____
31. District Procurement and Logistics plan developed
32. No. of PHCs/CHCs where AYUSH physicians posted
Current levels
i.e baseline
(give data
sources if
possible)
MIS
Levels to be
achieved in 0708
Levels to be
achieved in
08-09
Monthly
Progress
Reports from
States
MIS
Survey
The district planning team after weighing the pros and cons of the field situation and considering the
past trends and additional inputs that are forthcoming should set realistic objectives and there has to
be consensus on what has been proposed. Further, the teams will have to consider different options
of achieving the objectives. The exercise of detailing out strategies and interventions can be carried
out after block-level consultations.
73
During the block-level consultations, the situational analysis from DLHS and service statistics data
comprising of block-level analysis on few critical indicators should be shared in the form of power point
presentations. Later, the objectives decided by the district can be shared and the views of block
stakeholders can be solicited. Further, the district planning team can use a simple process by
conducting force field analysis to determine the pros and cons of achieving each of the objectives
stated above. An illustration of how it can be applied is shown below:
Force-field analysis is a useful technique for assessing all forces for and against a decision. In effect this is a specialized method of weighing pros
and cons.
By carrying out this analysis one can:
□
Plan to strengthen forces supporting a decision
□
Plan to reduce impact of opposition
The following steps have to be adopted:
□
List all forces for change in one column
□
List all forces against in another column
Once you have these viewpoints you can decide if you wish to go ahead with the proposed objective or would like to make any changes at this
stage.
Example: Force-Field analysis for Institutional Delivery
Factors for Change
■
JSY will facilitate/financial incentives
Additional ANMs/SNs
BCC for danger signs
Objective
Increase Institutional delivery
from current 20% to
in 2
years
People value Institutional Delivery
Factors against change
Social/cultural norms for HH
delivery
Women from BPL treated with
contempt in facilities
Staff not available round the
clock
Staff takes money
After the force-field analysis is carried out for each of the objectives, then the block will have to
determine ways of addressing the stated objectives.
Suggested list of Interventions to address the objectives
It is important for district planning teams to be aware of evidence based technical strategies to achieve
programme goals. In following matrix an attempt has been made to give the plausible list of
interventions can be suggested, which the district can choose or add and convert them into activities.
An indicative matrix of strategies by programme areas has been compiled and shown below. Specific
strategies could emerge during the consultative meetings at block and district levels. These specific
strategies should be factored in during the formulation of work-plan and budget.
To achieve the established programme objectives, the strategies and interventions will have to be
planned on the basis of suggestions obtained during block-level consultation meetings/As the format
for getting inputs proposes to use access, quality and demand framework, it is necessary to define the
strategies for programme areas by these parameters.
Merely identification of strategies and interventions, although necessary as a first step, is not sufficient.
Activities to operationalize these strategies will have to be identified. This process manual does not
plan to give a menu of activities, as this may preclude discussions.
74
Objectives & Strategies
1.
District Plan Objectives
Universal coverage of all
pregnant women with package
of quality ANC services as per
national guidelines
2.
Increase in deliveries with
skilled attendance at birth
including institutional deliveries
3.
FRUs (including DHs,
CHCs/PHCs) made functional
as defined in the National
RCH2PIP
4.
Universal coverage of all
eligible pregnant women under
JSY scheme
5.
Increase in percentage of new
born babies given colostrums
6.
Increase in prevalence of
exclusive breast feeding
Increase in fully protected
children in 12-23 months as
per national immunization
schedule__________________
8. Universal coverage with
Vitamin A prophylaxis in 9-36
months children____________
9. Percentage of severely
malnourished children below 6
yrs referred to medical
institutions________________
10. Unmet demand of
Contraception
Spacing
Limiting
7.
_____________________ Suggested Strategies_____________________
♦ Schedule out-reach sessions for ANC especially in inaccessible areas/
blocks by developing visit schedules and activity plans
♦ Re-orient ANMs in new guidelines for ANC as an integral component
of SBA
♦ Ensure availability of supplies i.e. ANC kits such as BP instrument,
foetoscope, Hb measurement, Urine examination
♦ Organise demand side so as to encourage pregnant women to seek
care as per schedule_________________________________________
♦ Civil works in form of labour rooms at facilities
♦ Additional human resources ANMs at sub centres
♦ Skill up gradation of ANMs In SBA
♦ Need based supplies for normal deliveries
♦ BCC: linkages with ASHA
♦
♦
♦
♦
♦
♦
♦
♦
Establishment of Blood Storage Facilities
Civil works in identified facilities for LR, OT and staff residences
Need based supplies of equipments/drugs
Deployment of critical staff as per guidelines
Skill up gradation of Doctors - life saving skills in anesthesia,
Emergency Obstetric Care (CS Section)
Training in Management of common obstetric complications_________
Adapt / Develop district specific guidelines for eligibility, transfer of
money and reporting mechanisms
Accreditation of private providers for eligible for benefits under JSY
BCC strategy for the communication objective of raising awareness
Orientation of community based functionaries such as
AWWs/TBAs/ASHAs
BCC with women’s group and PRI members______________________
Orientation of AWW/ASHA on lactation management
Communication activities
♦
♦
♦
♦
♦
♦
Development of facility based micro plans for out-reach sessions
Cold chain plan
Surveillance of VPDs
BCC for Immunization __________________________________
BCC
Ensuring supplies of Vit A through distribution system
♦
♦
Orientation of AWWs on grade III and grade IV malnutrition.
Orientation of Doctors at PHCs in management of grade III and grade
IV
♦
♦
♦
BCC on contraception
Alternative service delivery mechanism for FP supplies
24 x 7 PHCs provide regular clinical contraceptive services including
IUD insertions & IUD insertion
Accreditation of private providers for providing sterilization of IUD
♦
♦
♦
♦
♦
♦
services
♦
♦
Skill upgradation of Doctors in IUD insertion, male & female
sterilization
Skill upgradation of ANMs in IUD insertion
75
District Plan Objectives
11. Number of health institutions in
PHCs/CHCs offering ARSH
services___________________
12. Number of health institutions
providing services for
management of STIs and RTIs
13. Performance indicator for
NVBDCP
- API for MP
Annual blood examination rate
for MP increased (over 10% of
all OPD cases)
Slide Postivity Rate
Number of deaths due to
malaria
_____________________ Suggested Strategies____________________
♦ Regular contraceptive update trainings to health providers
♦ Need based supplies
♦ Block PHCs / CHCs / Sub District Hospital to provide fixed day female
and male sterilization services______________
♦ Orientation of MOs and ANMs in ARSH services
♦ Linkages with WCD/Education department
♦
♦
♦
♦
♦
♦
♦
♦
♦
a.
b.
c.
Malaria - As given in the
document
Filaria - Percentage of target
population consumed DEC
during MDA (Applicable to
endemic states only)
Kala-azar - Number of kalaazar cases detected and
received complete treatment
14. Performance indicator for
RNTCP
- Annual case detection rate
Proportion of new positives out
of total new cases
Treatment Success Rate
Conversion Rate
15. Performance indicator for
NLEP District Plan Objective
Further reduce prevalence at
district and sub-district level
Reduce new case Detection
Rate gradually
Provide quality leprosy
services to all leprosy patients
16. Percentage (as planned) of
ASHAs functional in the district
(received induction training)
♦
♦
Skill upgradation in new management protocols
Hiring of lab technicians
Need based equipments/supplies______________________________
Identify pockets populations at risk to have increased access to early
diagnosis and prompt treatment.
Activities such as antyi larval measures and spray to reduce malaria
transmission using appropriate preventive measures.
Ensure inter-sectoral collaboration at different levels to achieve the
collaboration between health and related sectors, private and NGO
sectors etc.
Bring about an improvement in surveillance, epidemic preparedness
and response.
Emphasize upon Behavioural Change communication and social
mobilization.
Human resource development and capacity building.
Convening meeting of district coordination committee under the
Chairmanship of District Collector
Identification and training of drug distributors at the village level
♦
All PHCs/CHCs having the facility for diagnosis and treatment of kalaazar cases.
♦
♦
♦
♦
♦
Quarterly observance of kala-azar fortnight for active cases detection.
BCC for improved treatment seeking behavior for TB suggestive
symptoms
Improvement in case finding activities in terms of strengthening,
identification and referral of TB suspects
Quality assurance of sputum microscopy network
Ensure proper categorization of TB patients
Ensure treatment compliance by the patient
Ensure regular drug supply____________________________________
Ensure quality diagnosis and proper categorization of patients at PHC
Ensure completion of treatment
BCC for motivation of patients having suggested signs of leprosy for
self reporting
Enhancing IEC activities to further reduce social stigma
Proper counseling of leprosy patients to prevent deformities
Human Resource Development and capacity building
♦
♦
♦
♦
Plan for identification of ASHAs
Finalize ASHA training programme
Procurement of kits to ASHAs
Support Mechanism for ASHA
♦
♦
♦
♦
♦
♦
♦
♦
76
District Plan Objectives
17. Number of RKS
registered/established
18. Number of Health care delivery
institutions upgraded
- SHCs
- PHCs
- CHCs
(these institutions should be in
conformity with IPHS)___________
19. Village Health and Sanitation
Committees constituted
Grants given_______________
20. Number of SCs strengthened
- Additional ANMs hired
- Annual maintenance grants
given_____________________
21. Number of PHCs strengthened
to provide 24 x 7
3 staff nurses hired
Annual maintenance grants
given_____________________
22. National Blindness Control
programme
- Cataract surgery rate
(450/100,000 population)
% surgery with IOL
23. Integrated Disease
Surveillance Programme
Number of labs to be upgraded
(L1 and L2)
Number of staff to be trained in
surveillance activities________
24. Staff for mobile medical units
in place
25. Number of facilities to be
covered for facility survey
- SHCs
PHCs
- CHCs________________
26. Number of villages to be
covered for HH survey
27. Number of Community
Hearings planned______
28. District Training plan
developed implemented
♦
♦
♦
♦
♦
♦
♦
♦
Suggested Strategies
Development/adaptation of model MOU
Formation of RKS and opening of bank accounts
Guidelines for RKS
Training of RKS members___________________
Facility survey completed
Deployment of staff
Civil works
Equipment and supplies
♦
♦
♦
♦
♦
♦
Guidelines for VHSC finalised
Opening of Bank Account
Orientation of VHSC members in NRHM
Criteria for identification of sub-centres
Contractual ANMs
Guidelines for use of maintenance grants by SCs
♦
♦
Hiring of additional staff, Nurses for 24 x 7 PHCs as per RCH-PIPs
Guidelines for use of maintenance grants by PHCs
♦
♦
♦
♦
Strengthening service delivery,
Developing human resources for eye care,
Promoting outreach activities and public awareness and
Developing institutional capacity.
♦
♦
♦
Assessment of labs and identification of needs for strengthening
surveillance activities
Training of staff for surveillance work
Contractual staff appointed for labs as per plan
♦
♦
♦
♦
♦
♦
♦
Identification of blocks requiring visits from the MMU
Staff deployment
Services to be offered through MMU
Procurement of drugs and medicines_______________
Finalisation of format for facility survey
Training/orientation of staff in conduct of facility survey
Sharing findings in monthly meeting and also with RKS
♦
♦
♦
Constitution and orientation of teams for HH survey
Finalisation of format and analysis plan__________
Guidelines for public hearings finalised
♦
♦
♦
♦
Assessment of training needs for different stakeholders
Development of a training plan based on the state guidelines
Implementation of the district training plan
Assessment of- existing availability;
- gaps
- yearly quantifiable training loads.
|
77
District Plan Objectives
________________
Suggested Strategies_______
♦ Detailed training heads:
egs.
No. to be trained in female sterilization
No. to be trained in male sterilization
No. to be trained in IUD
No. to be trained in contraceptive update
29. District BCC Plan developed
and implemented
30. District Procurement and
Logistics Plan developed
♦
♦
♦
♦
♦
Assessment of Communication needs for the district in the context of
NRHM
Development and Implementation of Communication Plan
Assess need for supplies and equipments based on norms and facility
survey
Develop plan for procurement at district level for supplies not coming
from the state
Finalise plans for reaching supplies at different levels of care including
ASHAs
__________________________________
31. Monitoring Mechanism
Services to be evaluated
Type of Services
(a)
(b)
(c)
Evaluation of contraceptive service provider - Similar to RET
(A team of district official/
Evaluation of institutional deliveries
NGO/PRI)
Evaluation of complete immunization
Monitoring of FP Service
Monitoring of Maternal ServicesMonitoring of Immunization
32. No. of PHCs/CHCs where
AYUSH physicians posted
Mechanism
♦
♦
Re-location of existing AYUSH dispensaries
Contractual appointment of AYUSH manpower
This process should be repeated for all the objectives/programme areas and should be put together at
the district level consultative meeting for finalizing the strategies and later details of rolling out the
strategies.
78
Ch^fe"
7
District Planning Workshop
7.1. You are here now
After setting your objectives as given in the chapter VI, at this stage of the DHAP preparation, you
should have with you the following:
1.
2.
3.
Information collated through the situational analysis1
Objectives and key strategies from the Block Level Consultations
Objectives, interventions and activities
And now this is also a time to roll in the plan centre stage and announce the plan and its proposed
outcomes. Refer the second column in the table under section 5.2 for ideas.
This purpose of this chapter is to provide some guidance on the District Planning Workshop.
The District Planning Workshop
7.2
The objective of the District Planning Workshop could be as follows:
•
•
To review and vet objectives of the District Health Action Plan (DHAP);
To assess appropriateness and adequacy of suggested strategic interventions/and activities to
meet the objectives of the DHAP;
The purpose of this workshop is also to share with a larger stakeholder group, the proposed outcomes
for the District and get a critical review and additional inputs.
While the scope of this chapter is to guide us through a District Planning Workshop to finalize the first
drafts DHAPs, the District Mission may decide to have one additional half day meeting. This could be
held after the first Draft of the DHAP is shared with the Blocks to consider any suggestions from the
blocks.
1 Refer Chapter 4 and 6 of the Manual.
79
Here is an indicative list of participants for the District Level Planning Workshop. This list is not
exhaustive and you may like to add few more names
District Collector - Chair for the workshop
CEO of the Zilla Parishad
NRHM Mission Director
Members of the District Mission
PRI representatives (10 at least 50 percent should be women)
District level officials from Health and Family Welfare Departments
District level officials from Line departments i.e. WCD, Water and Sanitation
Block Level Departmental Functionaries (especially from WCD, Health and Water Sanitation)
NGOs/CBOs
Networks of the Private service providers
7.4
The Design of Workshop
Planning Team
We assume that the District will establish a team to facilitate the overall DHAP process. The same
team could take responsibility to facilitate District Level Planning workshop.
Suggested Agenda for District Planning Workshop
Time
0930 hrs
1000 hrs
to
1100 hrs
1100 hrs
to
1200 hrs
1200 hrs
to
1300 hrs
1300 hrs
to
1400 hrs
1400 hrs
to
1600 hrs
1600 hrs
to
1700 hrs
_____________ Sessions/Activity____________
♦ Welcome and workshop objectives
♦ Introduction of participants
♦ Remarks by Chief Guest_________________
♦ District NRHM Scenario
Presentation
Discussions________________________
♦ Suggested programme objectives and strategies
Presentations
_______ Responsibility
District Planning Team
Convenor
♦
Key problems and solutions engaging the block
consultants
Presentation
Discussions_______________________
LUNCH
Member of Planning Team
Group Work
(Divide participants in 5 groups, i.e., New intervention
under NRHM.RCH, Immunisation, Disease Control
Programme and Intersectoral convergence)
Group work Terms of Reference
to be presented by the member
of the Planning Team
Terms of Reference
Each group to suggest solutions in from of feasible
activity to achieve programme objectives_______
Plenary Sessions
Wrap-up and follow-up
NRHM focal point of the
discussions
Planning Team Member
Rapporteurs will make the
presentation
80
Orpfer
8
Work Plan and Budget
As part of the operational^ manual for developing the^NRHM District Health Action Plans, it was
decided that we should/develop a model work pla<vz This would help facilitate the district group
preparing their DHAP to look at a model Work Plan and try to develop their own work plans based on
their own situations.
Program Managers and their staff use Work Plans as a management tool to plot their various main
and sub-activities at the beginning of the year. Once the activities have been planned, the managers
would then need to see how they have been adhering to the planned programs, where the pitfalls are,
the reasons why they lag behind the time schedule and the mid-course action required to correct them.
In effect, it is a monitoring tool for the program management staff.
Keeping these in mind, we have prepared two model Work Plans - viz, one month-wise and the
second quarterly. The month-wise plan is for one year, which would help the programmers to plan the
activities by month. The quarterly work plan is for two years, which could be used in plotting activities
for a quarter and would give a broad picture as to when the activity/program could happen.
We have looked at some of the State PIPs and have compiled the model work plan taking most of the
details given in them. We would, however, like to suggest the district team preparing their work plan
that they should use our compilation as a model only. We would urge that they should suitably adapt it
according to their and state’s priorities for NRHM/RCH II activities, while also taking into account the
national objectives and goals.
We have also done an average unit costing for some of the training programs and average costs for
other activities, which would happen in 2006-07. Again these are only average costs for 2006-07,
which we took from a particular state PIP. We would like to emphasize that the costs may vary from
district to district and from state to state. The district team and the state authorities are the best judges
in determining the costs. What we have given is only indicative average costs and you should use
your own judgment while working out the costs.
81
An indicative matrix containing average/unit costs is attached as annex 2 to the manual.
8.1 Work Plan of Activities
.
Scheduling of activities in a systematic way is another important featur^of this exercise. All activities
whether costed or not costed should be included in the Workplan.
When all the activities are worked out and time-line defined with responsibility, it will give an overview
of activities against which monitoring can be undertaken/ In other words, this matrix wiII facilitate in not
only providing information on when the activities have to be initiated and completed but car, be
effectively used for tracking the status of each of the defined activities along with monthly monitoring.
Since the responsibility has been assigned for each of the activity, it is expected to enhance
accountability of the person, ■
Let us now continue with the example cited in Chapter 6 where maternal health strategies were
defined for access, quality and demand. The broad strategies now have to be converted into
implementable activities. How can this be done is illustrated in the following discussions.
8.2 Programme Component: Maternal Health
Programme Objective:
Universal coverage of all pregnant women with package of quality ANC services as per national
guidelines
Programme Strategy:
Strengthening outreach sessions for ANC
ThAuestion one should ask is what all activities have to be initiated to implement this strategy and
how best it can be done? Invariably these activities and sub-activities may link during block and district
level meetings. During the block level consultation and district planning meeting, strategies and
activities are likely to be spelled out. A sub-group of district planning team should develop a role out
plan for the activities. The Workplan gives a framework to schedule the activities, time duration.
In order to strengthen outreach sessions for ANC, locations have to be decided, frequency of
conducting outreach, any partnership with other stakeholders is required or not should be discussed,
what demand generation activities will have to be undertaken have to be decided^ This apart,
orientation of ANM’s to the new national guidelines and then necessary supplies for conducting
outreach sessions will have ensured and implemented. All these activities will have to be scheduled
systematically and put in the work plan.
These are more facility-based activities and the listing of activities for operationalizing the strategy look
simple and straightforward but in reality it is not so. At district level, the manager has to ensure that
necessary pre-requisites are in place/ These will guide the manager more because absence of it
means, it is difficult to roll out the activities.
For instance, the manager has to see and analyze what are the activities around the strategy. If the
activity depends on training, the manager needs to know whether it is imparted or not and in regard to
82
ensuring supplies, which is true in most of the interventions, logistics management system is in pla^e/
or not and if not what other actions will have to be initiated. Further, the manager will have to make
sure that appropriate demand generation capacity building is undertaken and later the activities are
rolled out and monitored periodically. To do all these, there is a need to identify focal points at the
district level.
While these factors guide the district manager the facility level is guided by operationalizing the
activities. This distinction applies to all the other strategies and the district level activities cuts across
other strategies as well. In other words, the district level activities would be more or less common.
/
At the district level, there is therefore a need tc/identify focal points for undertaking each of the
specialized tasks stated above and with NRHM adopting decentralization approach the onus of
responsibility is more at the district level. So, if district in intending to implement this strategy then the
following steps will have to be followed:
Strategy: Strengthen Outreach sessions for ANC services
Activities-District
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
Ensured training of trainers in new guidelines of ANC care-This would, by and large, depend on
when the state initiates training of trainers. So the work plan or initiation of the activity should
align with state-level strategies.
Initiated training of ANMs in new guidelines and on-going
Logistics System in place and staff oriented-This is also a state-level activity and with
decentralized procurement being the modality in NRHM, necessary capacity should be made
available. Knowledge of rate contract list and procedures of tendering etc. are essential inputs
necessary for smooth management
Necessary kits required for ANC sessions procured and distributed
Staff identified and made responsible for BCC activities- Usually multi-media activities are
undertaken at state level. However, to roll out district-specific interventions and for imparting
IRC skills to staff it is necessary to have trained persons
Training of staff members in IRC and demand generation initiated and on-going
District officers tasked with responsibilities for roll out
Calendar^foj; conducting monthly outreach sessions for ANC prepared and finalized along with
ICDS department and shared with District society members
Implementation calendar for outreach sessions for ANC shared with block level officers
Monitoring system put in place and outreach sessions initiated
Activities-Facility level
♦ Calendar of outreach sessions prepared and finalized for the area
♦ Necessary supplies for ANC sessions estimated and supplied
♦ PRI’s, AWW’s and ASHA’s oriented in undertaking mobilization activities
♦ Calendar of outreach in the area of each PRI shared in advance and type of services that will
be provided shared
♦ PRI’s along with AWW’s and ASHA’s undertake publicity activities
♦ Outreach sessions on ANC initiated in AWC villages
After having listed these activities, we will now use this information and assign them in the matrix
below.
83
ILLUSTRATIVE TEMPLATE FOR PREPARING WORK PLAN
DISTRICT ACTION PLAN: WORK PLAN FOR TWO YEARS
Sr No.
Activity
Time frame 2007-09
2007-08 _______
04
02
03
01
1
1.1
Responsible
Person(s)
2008-09
06
05
07
08
MATERNAL HEALTH
Universal coverage of all
pregnant women with
package of quality ANC
services as per national
guidelines_____________
Strengthen outreach
sessions for ANC-District
Level_________________
1.1.1 Access:
♦ Develop guidelines
for sector-wise micro
plans for outreach
sessions and use of
money
♦ Additionally identify
under-served areas
1.1.2 Quality
♦ Orientation training of
ANMs in new
guidelines
♦ Procurement of kits
for ANC___________
1.1.3 Demand
♦ Organise of safe
motherhood day by
village health and
sanitation committee
♦ Development and
multiplication of Flash
Book to be used by
ASHA/AWWs______
From the above matrix, we have been able to demonstrate of how to convert strategies into activities.
The timing of activities was planned and the responsibility for each activity was assigned as well. This
way, each of the strategies listed in Chapter 6 will have to be operationalized. By doing so, concurrent
and complementary activities can also be identified.
84
Ch^te'
9
Monitoring & Evaluation including Programme Management
After having finalized the work-plan and initiated the proposed interventions, there is a need to not only
continuously monitor the inputs but also collect basic information on the' progress of activities and its
performance periodically^ so that thp^programme manager is able to track both the inputs and
processes as wel^/Momtoring of indicators proposed in the work-plan will enable in input monitoring of
whether the activities have been initiated as per the schedule or not while monitoring the performance
at regular intervals will give an idea of the progress made in these indicators. The two together will
give an overview of progress that has to be addressed during monthly review meetings held at
different levels of the health system^
The state RCH PIP document has already listed a set of input and process indicators and has decided
on the frequency of monitoring. Likewise, there are set of indicators for communicable and noncommunicable diseases, which is being collated and sent to the respective divisions of the central
health ministry. Presently, the requirements of the NRHM have changed and an integrated approach
is envisaged with disaggregated information on a few selected indicatqr^X Hence the monitoring
system for all the health and reproductive and child health programmes will have to be fine tuned at
different levels of the health system to address the specific NRHM requirements and collated into a
single format.
Further, the NRHM has strongly advocated community monitoring and reporting. Although this
element is yet to be piloted or pre-tested within the health system, there have been few instances
where such similar experiments have been undertaken external to the health system. Through this
mechanism, dialogue between providers and community has taken place and the results have been
encouraging (Refer: Jansuvahi in Haryana supported by UNFPA and that of JSA network). The
experiences of these project-based experiments will have to be internalized and mainstreamed with
the routine monitoring system. Besides, the establishment of citizen’s charter and the activation of
Village Health and Sanitation Committees provide additional opportunities for experimenting
community monitoring and reporting. It is therefore, suggested to develop different mechanisms of
community reporting and choose the most appropriate mechanism for the district.
This apart, a system for assessing quality of services is being developed through a pilot study. The
details of assessing quality of services, is being worked out. To begin with, this activity will be pre
tested in districts of few selected states through external facilitation, wherein the methodology of
conducting the study, details of number of health institutions to be covered, frequency of visiting the
institutions, pedagogy and so on will be finalized and replicated.
As the aim is to ultimately
institutionalize quality assessment in routine monitoring, the M&E cell along with the contracted
agencies will work out a practical mechanism for institutionalizing these elements. This would not only
facilitate in creating in-house resource, but will also help in capacity building of programme managers
at the district and below levels.
85
Performance evaluation mechanism will mostly rely on baseline (CNAA, RHS reports at district level
and other special studies), concurrent, mid-term and end-line surveys. There would be both internal
and external as government and non-government agencies will be involved. Besides qualitative
studies and community reporting will be done to supplement impact assessment studies. Mainly, the
evaluation system will rely on District surveys (RHS and Facility) of 2007 and 2010 respectively. List
of input, programme and output indicators that have to be monitored and evaluated as part of NRHM
are as follows:
Input Indicators
/
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
□
Number of additional ANMs positions filled against required
Number of ASHAs selected and trained
Number of SC’s strengthened against proposed
% of ASHAs in position
Number of VH&SC constituted and grants given (proposed vs actual)
Number of RKS registered/established against proposed
NumberofCHCs upgraded as per IPHS
.
Number of PHCs strengthened to provide 24*7 services (No. proposed and actual functioning)
% of upgraded CHCs providing EmOC services (No. proposed and actual functioning)
Number of static facilities offering sterilization services (Male and Female)
Number of DH/SDH/CHC/Block PHC providing sterilization services
- male - NSV
- Female - Minilap / Laparo. Ster.
Number of CHC/PHC/SC providing IUD services
Frequency of provision of service at different places (DH/SDH/CHC/PHC/SC) - fixed day or not
Number of trained and certified trainers and providers available for NSV/mimlap / laparo / IUD
Number of CHCs/PHCs providing RTI services ( % of the total)
Number of PHCs/CHCs providing ARSH services
% of health facilities (CHCs/PHCs) not having at least one month stock of anti-TB drugs,
measles vaccine, OCP and gloves
% of outreach sessions where AD syringe and safe disposal needles are used (Total outreach
session is the base)
Process Indicators
9.2 Maternal Health
□ ANC registration during the first trimester (Separately for vulnerable groups and others)
□ Total ANC Coverage for different ANC services (Separately for vulnerable groups and others)
□ Number of eligible pregnant women receiving complete ANC package (Base 7-9 months
□
□
□
□
□
pregnant women) (Separately for vulnerable groups and others)
% of pregnant women with obstetric complications identified and treated (Separately for
vulnerable groups and others)
% deliveries with skilled attendance including institutional deliveries (Separately for vulnerable
groups and others)
% of C-section deliveries and institution break-up of C-sections (Separately for vulnerable
groups and others)
Coverage of eligible pregnant women covered under JSY (Separately for vulnerable groups
and others)
Number of women receiving post-partum care within two weeks of delivery (Separately tor
vulnerable groups and others)
86
□ % of pregnant women having 4 or more living children
□ Number of maternal deaths by weeks after births (by caste) (Separately for vulnerable groups
and others)
□ Number and percent of 24 hour PHCs conducting minimum of 10 deliveries per month
□ Number and percent of FRUs, CHCs and 24 hrs. PHCs reporting having conducted at least 10
wet mount test in the months
9.3 Child Health
□ Number of live births by sex and caste
□ % of live births weighed
□
□
□
□
□
□
% of infants underweight
Number of infant/child deaths
Number of infants (0-11 months) by vaccination status-by sex and caste
Number of 9-36 month old given Vit A-by sex and caste
Number of children severely malnourished children (<6 yrs by sex and caste) referred to
institutions
Number of children who suffered from diarrhoea/ARI and % who sought treatment
9.4 Family Planning
□ Number of female and male sterilization operations performed during the month
□ Number of new and continuing spacing method users
□ Parity of sterilization acceptors
□
□
□
□
□
□
Mean age of sterilization acceptor
% deaths, failures, complications reported
% compensated through National FP Insurance Scheme
% of correctness of Sterilizations and IUDs reports
Release of compensation money as against number of cases done
% of ELAs covered
87
NVBDCP
NVBDCP should be considered with the following input and programme output indicators.
Input
Percentage of PHCs having functional laboratory for malaria microscopy
Percentage of DDCs/FTDs/ASHA/AWW reporting stock out of antimalarial drugs/anti kalaazar drug (endemic PHCs only) during last three month
Percentage of PHCs/CHCs with facilities for treatment of Acute Encephalitis Syndrome (in JE
endemic areas)
Percentage of PHCs/CHCs having facilities for detection and treatment of Kala-azar cases
Programme Output Indicator
Percentage of target population screened for malaria parasite
Percentage of positive malaria cases radically treated within 72 hours of blood smear
collection
Number of severe cases of malaria treated at the PHCs/CHCs
Number of cases of Acute Encephalitis Syndrome managed at PHCs/CHCs (in JE endemic
districts)
Number of hydrocele operations conducted at PHCs/CHCs (in Filaria endemic districts)
Number of Kala-azar patients completely treated at the PHCs/CHCs
-API for MP
-Annual blood examination rate for MP increased (over 10 % of all OPD cases)
-Slide Postivity Rate
-No of deaths due to malaria
RNTCP should be considered with the following indicators.
-Percentage of PHC/CHC having RNTCP DMC with functional BM (Binocular Microscope) and
trained Lab technician
-Percentage of TB suspects examined out of the total outpatients
-Annualized New Smear Positive (NSP) case detection rate per 100,000 populations
-Annualized Total Case detection rate per 100,000 populations
-Treatment success rate
NLEP should be considered with the following indicators.
- PR
- ANCDR
- Proportion of MB, Female, Child, ST, SC cases among the new cases detected
- Proportion of Patients completed treatment
88
NIDDCP should be considered with the following indicators.
Indicator
Numerator
Denominator
No.
of
districts
surveyed/resurveyed &
endemic to IDD where
prevalence is >10% in
the State
Total
No.
of
districts surveyed/
resurveyed
&
endemic
having
>10% quarterly
Target for IDD Survey/Resurvey for the year
No. of iodated salt
samples analyzed per
district
Total
No.
of
iodated analyzed
quarterly
Target for iodated salt analysis for the year
No. of urinary iodine
excretion
samples
analyzed per district
Total
No.
UIE
samples quarterly
Target for UIE sample analysis for the year
Expenditure of State
IDD
Cell,
IDD
Monitoring lab, survey
and health education
monthly
Expenditure made
quarterly
Fund allocated for the year
89
National Blindness Control Programme
- Cataract surgery rate (450/100,000 population)
-% surgery with IOL (80%)
- % School Eye Screening
- Screening of school children for defection of refractive errors and providing 3.1 lakh free spectacles
to poor children
- Collection of 1.75 lakh donated eyes (after death) for transplantation in persons with corneal
blindness
(
- Setting up 2000 vision centres in rural areas at Primary Health Centres and NGO facilities for
providing basic services to rural population
- Providing non-recurring to 50 voluntary organizations for strengthening/expandmg eye care
services
Output Indicators through evaluation
■
■
■
■
6
Contraceptive prevalence rate
% eligible couples using any spacing method for more than 6 months
% of eligible couples of higher order of births (3 & 3+), accepted permanent method
% of women delivered during past one year who received 100 IFA tablets
% deliveries conducted by skilled providers (doctors, nurses or ANMs)
% of 12-23 months children fully immunized
.
% of mothers and newborn children visited within 2 weeks of delivery by a trained community
level health provider/AWW or health staff (ANM/Nurse/Doctor)
% of children suffering from diarrhea during past 2 weeks received Oral Rehydration Solution
Polio free status achieved
Total number and percentage of vulnerable groups with reference to the total population of the
area and total number and percentage of the vulnerable groups covered under the
programme vis-a-vis others.
In sum information on these indicators will have to be gathered by SC, ST and others and wherever
applicable by male and female. The new monitoring format that is going to be introduced from the
state to national levels is being finalized and takes the above elements into consideration.
90
NRHM Management Structures
A programme that seeks to decentralize with adequate devolution of powers and delegation of
responsibilities has to have an appropriate implementation mechanism that is accountable./^ order to
facilitate this process and implement the DHAP, the NRHM has proposed a structure right from the
village to the national levels with details on key functions and financial powers (Refer the document on
NRHM-Framework for District Planning for Health, Ministry of Health and Family Welfare, 2006 for
more details).
Broadly, the flow chart from National to Block levels would be:
FLOW CHART
PROGRAMME MGT.
SUPPORT
National Level
NATIONAL MISSION
DIRECTOR
State Level
STATE MISSION
DIRECTOR
District Level
DISTRICT MISSION
DIRECTOR
Block Level
PROG. SUPPORT
TEC.
NHSRC
NRHM
CELL/NIHFW
BLOCK PUBLIC
HEALTH MISSION
SHSRC
SPMU
>
DHSRC
DPMU
BPMU
<
> BHSRC
y
This way, the NRHM proposes to support rolling out of activities and the programme and the technical
units will have to be put in place by the respective states in accordance to the guidelines.
The Ministry is currently finalizing the MIS format for NRHM.
format is at Annexure-VIII.
However, the preliminary monitoring
91
Chepk
10
Structure of the District Health Action Plans (DHAP)
Activities suggested in the previous sections of this manual will enable by the district planning team to
organise in form of DHAP document. The DHAP is the ultimate product of the entire planning exercise
and will be reference document for district NRHM management. In this chapter a structure of this
document is being suggested:
10.1 Background:
This section should include information on geographic location, socio-demographic profile of
the district and also information on key health indications from recent data sets.
10.2 Situation Analysis
District team should reflect on following parameters while giving analysis in key programme
areas:
♦
♦
♦
♦
♦
Coverage with preventive/promotive interventions
Income and Gender equity
Underserved population groups
Quality of services - service quality and community perspectives
Programme environment — vacancy, physical, infrastructure etc.
10.3 Process for Plan Development
It will be appropriate to describe processes undertaken such as any specific desk reviews
commissioner, block and district level consultations and profile of participants, participation
from other sectoral departments in the planning process. A brief introduction to profile of
members included in the district planning team may be also useful.
10.4 Objectives
As per Chapter 6 and also Chapter 7, objectives set out for the districts in year 2007-2008 and
2008-2009 should be spelled out giving qualitative levels of achievements. This should be
followed by a Matrix on key strategies and activities to operationalise the key strategies. Both
costed and has costed activities be reflected here. Wherever possible activities should be
quantified and geographical spread be delineated.
92
r‘
10.5 Workplan
Workplan should reflect in a matrix form and how different activities will be conducted with
special references to time frame and also identify responsible official or agency as the case
may be.
10.6 Monitoring & Evaluation
Essential components of this Chapter should be in synergy with larger NRHM monitoring^Flow
of data from different levels, i.e., service delivery, community monitoring and long scale data
sets is considered.
^10.7 Budget
Unit costs should be given for each costed activity and source of funding be also reflected.
Annexures, if any
93
ANNEX-I
Village Health Information Schedule
Block O. Identification Block
State/UT
District
Taluk / Block
Village
Panchayat
Household Address
Reference Month
Reference Year
Block 1. Housetiold Details
S.No.
1.1.
Name of the Head of
Household
1.2.
Sex of the Head of Household
1.3.
Number of Members in the
Household
1.3. a.
Males
1.3. b.
Females
1.4.
Type of House
1.5.
Ownership of House
'
A
V;s
Pucca
Own
Semi-pucca
Kachha
Rented
94
S.No.
1.6.
Number of separate rooms in the house
1.7.
Is there a separate room for kitchen? (Yes / No)
1.8.
Whether toilet facility available inside the
household? (Yes / No)
1.9.
Is there a community toilet facility in the village?
(Yes I No)
1.10.
What is the main source of lighting in the
household? (Specify) (Electricity/Kerosene
lamp/ others)______________________________
Is there a regular source of drinking water in the
household? (Yes / No)
(Specify the source of drinking water)_________
Whether the source of drinking water change
from season to season? (Yes / No)
1.11.
1.12.
1.13.
What type of fuel is used for cooking? (Specify)
1.14.
Main occupation of the household
1.15.
Number of earning members in the household
1.16.
Monthly income of the household
1.17.
Whether food is available throughout the year?
(Yes / No)
1.18.
If no, the difficult months for food availability
1.19.
What is the mode of transport available in the
household (if any)?
1.20. a.
Does the household own a TV? (Yes / No)
1.20. b.
Does the household own a Radio (Yes/No)
1.21.
Does the household own any agricultural land?
(Yes I No)
1.22.
Area of the agricultural land, if any
1.23.
Area of the agricultural land irrigated, if any
1.24.
Does the household own any livestock? (Yes /
No) (Specify)
95
Block 2. Health and Family Welfare
S.No.
2.1.
Number of children aged less than one year
(Infants)
Male
Female
2.2.
Number of children aged 0 to 5 years
Male
Female
2.3.
Number of children aged 6 to 14 years
Male
Female
2.4.
Number of births in the family during last one
year
Male
Female
2.5.
Any marriage in the family during last one
year?(Yes I No)
2.6.
Age of the person at marriage (if answer to
column 2.4. is ‘yes’)
2.7.
Number of currently pregnant women
2.8.
Deaths
2.8.a
Any deaths reported in the family during last
one year
2.8.b
Any deaths of children aged less than one
year reported during last one year
Male
Female
2.8.C
Any deaths of children aged less than five
years reported during last one year
Male
Female
2.8.d
Any maternal death reported due to causes
related to pregnancy I child birth during last
one year
2.8.e.
Whether any trained medical attention was
given to pregnant women?(Yes / No) (if
answer to column 2.4.d. is yes)
Age
Male
Female
Age
96
2.9.
Diseases and illness
2.9.a
Anyone suffered from any of the following
diseases during last three months
Asthma
Tuberculosis (TB)
L/
Malaria
Jaundice
Iodine deficiency disorder
2.9.b.
If suffered from TB, has he/she received any
treatment? (Yes / No)
2.10.
Food habits
2.10.a.
Food habits of the family (Veg. / Non-veg.)
2.10.b.
Anyone in the family chew Paan Masala or
tobacco? (Yes / No)
2.10.C.
Anyone in the family smoke? (Yes / No)
2.10.d.
Anyone in the family drink alcohol? (Yes / No)
2.11.
Health services
2.11.a.
When members of the household get sick,
where do they generally go for treatment?
2.11.b.
Whether health service provided public or
private?
2.11.C.
Expenditure incurred on seeking health
care during last one month
2.11.d.
Items on which money spent for seeking
health care during last one month
(Doctors fee / drugs / special food /
transport / others
1 4
fv'
97
ANNEX-II
Proforma for Sub Centres on IPHS
Proforma for Sub Centres on IPHS
Identification
Name of the State:
District:
Tehsil/Taluk/Block
Name of the Village
Location Name of Sub Centre:
Date of Data Collection
Day
Month
Year
Name and Signature of the Person Collecting
Data
I. Services
S.No.
1.1.
1.2. "
1.2.1.
_________ cL
b.
c.
d.
e.
f.
gh.
_E
k.
Population covered (in numbers)
MCH Care including Family Planning
Service availability (Yes I No)
Ante-natal care
_
Intranatal care
Post-natal care__________________
New born Care________________
Child care including immunization
Family Planning and contraception
Adolescent health care___________
Assistance to school health services
Facilities under Janani Suraksha
Yojana_______
_____________
Treatment of minor ailments_______
First aid (specify)
98
1.2.2.
a.
L
c.
d.
e.
Availability of specific services (Yes I
No)
Does the doctor visit the Sub centre at
least once in a month?_______________
Is the day and time of this visit fixed?
Are the residents of the village aware of
the timings of the doctor's visit?
Does the Health Assistant (male) or
LHV visit the Sub Centre at least once a
week?____________________________
Is the Antenatal care (Inj. T.T, IFA
tablets, weight and BP checkup)
provided by those in the Sub centre?
f.
Is the facility for referral of complicated
cases of pregnancy / delivery available
at Sub centre for 24 hours?
g-
Does the ANM/any trained personnel
accompany the woman in labor to the
referred care facility at the time of
referral?
Are the Immunization services as per
Government schedule provided by the
Sub centre
h.
i.
J.
Is the ORS for prevention of diarrhea
and dehydration available in the
Subcentre?________________________
Is the treatment of minor illness like
fever, cough, cold, worm disinfestation
etc. available in the Sub centre
k.
Is the facility for taking Peripheral blood
smear in case of fever for detection
available in the Sub centre?
I.
Are the contraceptive services like
insertion of Copper-T, distributing Oral
contraceptive pills or condoms provided
by the Sub centre?__________________
Is it a DOT centre?
Other functions and services
performed (Yes / No)
m.
1.3.
a.
bT
c.
d.
e.
Disease surveillance_________________
Control of local endemic diseases______
Promotion of sanitation_______________
Field visits and home care____________
National Health Programmes including
HIV/AIDS control programes
Monitoring and Supervision
activities (Yes I No)
a.
Training of traditional birth attendants
and ASHA_________________________
Monitoring of Water quality in the village
1.4.
b.
99
c. Watch over unusual health events
d7 Coordinated services with AWWs,
e.
f.
g-
h.
ASHA, Village Health and Sanitation
Committee, PRIs__________________
Coordination and supervision of
activities of ASHA
Proper maintenance of records and
registers_________________________
Is there a Village Health Plan / Sub
Centre Plan?
Is the scheme of ASHA implemented in
Sub Centre?
II.
Manpower
Existing
Recommended
Health Worker (Female)
1
1 or 2
(Optional)
2.2.
Health Worker (Male)
1
1 or 0 (optional;
may be
replaced by
female health
worker)
2.3.
Voluntary worker to keep the Sub
Centre clean and assisting ANM. She is
paid by the ANM from her contingency
fund @ Rs. 100 per month
1
(optional)
1 (optional)
S.No.
Personnel
2.1.
Current
Availability
at Sub
Centre
(Indicate
Numbers)
Remark
sI
Sugges
tions /
Identifi
ed
Gaps
If
available,
area in Sq.
mts.)
Remark
s/
Sugges
tions /
Identifi
ed
Gaps
III. Physical Infrastructure (As per specifications)
Current
Availability at
Sub Centre
S.No.
Location
3.1.
a.
Where is this Sub Centre located?
Within Village Locality
Far from village locality
100
b.
c.
d.
e.
f.
3.2.
a.
b.
c.
d.
e.
f.
9-
h.
J-
i.
ii.
iii.
iv.
k.
3.3.
3.4.
9
3.5.
3.6.
a.
b.
If far from locality specify in km________________ _
Whether located at an easily accessible area?
(Yes/No)________________ ________________________________________________
The distance of Sub Centre (in Kms.) from the
remotest village in the coverage area
Travel time to reach the Sub Centre from the
remotes place in the coverage area__________________________________________
The distance of Sub Centre (in Kms.) from the PHC_____________________________
The distance of Sub Centre (in Kms.) from the CHC
Building______________________________________ _______________ ___________
Is a designated government building available for the
Sub Centre? (Yes / No)
_______________ _
If there is no designated government building, then where does the Sub Centre located
Rented premises__________________________________________________________
Other government building_________ ________________________________________
Any other specify_________________________________________________________
Area of the building (Total area in Sq. mts.)_____________________ _
What is the present condition of the existing building_____________________________
What is the present stage of construction of the building______________ _
Construction complete_____________________________________________________
Construction incomplete____________________________________________________
Compound Wall / Fencing (1 -All around; 2-Partial; 3None)_________________ __________________________________________________
Condition of plaster on walls (1- Well plastered with
plaster intact every where; 2- Plaster coming off in
some places; 3- Plaster coming off in many places or
no plaster)_______________________________________________________________
Condition of floor (1- Floor in good condition; 2- Floor
coming off in some places; 3- Floor coming off in
many places or no proper flooring)___________ .___________________________
Whether the cleanliness is Good / Fair /
Poor?(Observe)___________________________________________________________
Are any of the following close to the Sub Centre?
(Observe) (Yes/No)
________________ _
Garbage dump
_______________________________________________ ________
Cattle shed____________________________________________________________
Stagnant pool_________ _ ____________________________________________
Pollution from industry___________ __________________________________________
Is boundary wall with gate existing? (Yes / No)__________________________________
Prominent display boards in local language (Yes/No)___________________
Separate public utilities for males and females
(Yes/No)____________________ __________________________________________ _
Suggestion / complaint box (Yes/No)______________
Labour room__________________________________________________ ___________
Labour room available? (Yes/ No)____________________________________________
If labour room is present, are deliveries carried out in
the labour room?__________________________________________________________
Yes _________________________ _________ __________________________________
No _____________________________________ _______________________________
Sometimes
101
1U
c.
If labour room is present, but deliveries not being
conducted there, then what are the reasons for the
same?
__________________________ __ _____
Staff not staying
Poor condition of the labour room_________________
No power supply in the labour room
__________
Any other specify
__
Clinic Room
__________ __________
Examination room
_____
Water supply________________________ ________
3.7.
3.8.
3.9.
a.
Source of water (1- Piped; 2- Bore well/ hand pump /
tube well; 3- Well; 4- Other (specify))
b.
Whether overhead tank and pump exist (Yes / No)
c.
d.
3.10.
3.11.
3.12.
a.
3.13.
If overhead tank exist, whether its capacity sufficient?
(Yes/No)
__
__ ____________ ________
If pump exist, whether it is in working condition? (Yes
/No) ___________ __________________________
Waste disposal__________________ ___________
How the medical waste disposed off (please
specify)?
Electricity
______________________
Regular electric supply available? (Yes
/No)
__________
Communication facilities
_
Telephone (Yes/No)
_________________
Transport facility for movement of staff (Yes / No)
3.14.
Residential facility for the staff
3.15.
Health Worker (Female)
___________
_
Whether Health Worker (Male) available in the Sub
Centre?
___________________
Is he staying at Sub Centre Head Quarter village?
(Yes / No)
__________
3.16.
Current
Availability at
Sub Centre
If
available,
area in Sq.
mts.)
If
availabl
e,
whethe
r staff
staying
or not?
IV. Equipment (As per list)
Equipment
Available
Functional
Remarks I
Suggestions /
Identified Gaps
102
e
V. Drugs (As per essential drug list)
Remarks I
Suggestions /
Identified Gaps
Available
Drug
VI. Furniture
S.No.
6.1.
6.2.
6.3.
6.4.
6.5.
6.6.
6.7.
6.8.
6.9.
6.10.
6.11.
6.12.
6.13.
6.14.
6.15.
6.16.
6.17.
6.18.
6.19.
6.20.
6.21.
6.22.
6.23.
6.24.
6.25.
Current
Availability at
Sub Centre
Item
Examination Table__________
Writing Table
Armless chairs_____________
Medicine chest_____________
Labour table_______________
Wooden screen
_______
Foot step_________________
Coat rack _____ _ _____ _
Bed side table
_______ _
Stool _____ _____________
Almirahs__________________
Lamp
Side wooden racks_________
Fans_____________________
Tube lights
_____________
Basin stand
ckets
If
available,
numbers
Remark
sI
Sugges
tions I
Identifi
ed
Gaps
_______________
Mugs ________________
Kerosene stove
Sauce pan with lid__________
Water receptacle___________
Rubber / plastic shutting_____
Talquist Hb scale_______
Drum with tap for storing water
Others (specify)
103
VII. Quality Control
S.No.
7.1.
7.2.
7.3.
7.4.
Particular
Whether functional I available as per
norms
Remark
s
Citizen’s charter in local
language(YesZNo)
________
Internal
monitoring:
supportive
supervision and record checking at
periodic intervals by the male and
female health supervisors from PHC (at
least once a week) and by MO (at least
once in a month) _____ __________
External monitoring: Village health and
sanitation committee, evaluation by
independent external agency_________
Availability of various guidelines issued
by GOI or State Govt, (specify)
104
ANNEX-III
Proforma for PHCs on IPHS
Identification
Name of the State:
District:...
Tehsil/Taluk/Block
Location Name of PHC:
Is the PHC providing 24 hours and 7 days delivery
facilities
Date of Data Collection
Day
Month
Year
Name and Signature of the Person Collecting Data
I. Services
S.No.
1.1.
1.2.
a.
b.
c.
d.
Population covered (in numbers)__
Assured Services available (Yes/No)
OPP Services
____________ _
Emergency services (24 Hours)______
Referral Services__________________
In-patient Services
1.3.
a.
Number of beds available
b.
Bed Occupancy Rate in the last 12
months (1- less than 40%; 2 - 40-60%; 3
- More than 60%)
1.4.
a.
b.
1.5.
a.
b.
c.
Average daily OPP Attendence
Males_____________________________
Females
Treatment of specific cases (Yes I No)
Is surgery for cataract done in the PHC?
Is the primary management of wounds
done at the PHC?
Is the primary management of fracture
done at the PHC?
105
d.
Are minor surgeries like draining of
abscess etc done at the PHC?
e.
Is the primary management of cases of
poisoning / snake, insect or scorpion bite
done at the PHC?
f.
Is the primary management of burns
done at PHC?
MCH Care including Family Planning
1.6.
1.6.1.
______a^
b.
c.
d.
e.
f.
9h.
i.
1.6.2.
a.
b.
Service availability (Yes I No)
Ante-natal care
Intranatal care (24 - hour delivery
services both normal and assisted)
..
Post-natal care
__
New born Care__________ _______
Child care including immunization_______
Family Planning
___________
MTP
_________________________
Management of RTI / STI
_
Facilities under Janani Suraksha Yojana
Availability of specific services (Yes I
No)
_________________ _________
Are antenatal clinics organized by the
PHC regularly?_____________
Is the facility for normal delivery available
in the PHC for 24 hours?
c.
Is the facility for tubectomy and
vasectomy available at the PHC?
d.
Is the facility for internal examination for
gynaecological conditions available at the
PHC?
_______________________
e.
Is the treatment for gynecological
disorders like leucorrhoea, menstrual
disorders available at the PHC?
f. 7f woTnen do not usually go to the PHC,
then what is the reason behind it?
gh.
Is the facility for MTP (abortion) available
at the PHC?
_________
Is there any precondition for doing MTP
such as enforced use of contraceptives
after MTP or asking for husband's
consent for MTP?
Do women have to pay for MTP?
j-
Is treatment for anemia given to both
pregnant as well as non-pregnant
| women?
106
k.
I.
Are the low birth weight babies managed
at the PHC?
___________________
Is there a fixed immunization day?
m.
Is BCG and Measles vaccine given
regularly in the PHC?
n.
How is the vaccine received at PHC and
distributed to Sub Centres?
o.
Is the treatment of children with
pneumonia available at the PHC?
P.
Is the management of children suffering
from diarrhea with severe dehydration
done at the PHC?
Other functions and services
performed (Yes / No)
1.7.
a.
b.
c.
d.
e.
L
g-
Nutrition services____________________
School Health programmes____________
Promotion of safe water supply and basic
sanitation
Prevention and control of locally endemic
diseases
Disease surveillance and control of
epidemics___________ ______________
Collection and reporting of vital statistics
Education about health / behaviour
change communication
h.
National Health Programmes including
HIV/AIDS control programes
AYUSH services as per local preference
Rehabilitation services (please specify)
Monitoring and Supervision activities
(Yes I No)
a.
Monitoring and supervision of activities of
sub-centres through regular meetings /
periodic visits, etc.
b.
Health
Monitoring
of
National
Programmes
_______ _________
Monitoring activities of ASHAs_________
Visits of Medical Officer to all sub-centres
at least once in a month
1.8.
c.
d.
e.
Visits of Health Assistants (Male) and
LHV to sub-centres once a week
107
II.
Manpower
S.No.
Personnel
Existing
pattern
Recommended
2 (one may be
from AYUSH
and one other
Medical Officer
preferably a
Lady Doctor)
2.1.
Medical Officer
1
2.2.
Pharmacist
1
2.3.
Nurse - Midwife (Staff Nurse)
1
2.4.
2.5.
1
1
2.7.
2.8.
Health Worker (Female)__________
Health Educator
Health Assistant (One male and One
female_________________________
Clerks_________________________
Laboratory Technician
2
1
2.9.
Driver
1
2.10.
Class IV
Total
£
4
15
17/18
2.6.
2
Current
Availability
at PHC
(Indicate
Numbers)
Remarks /
Suggestion?
I Identified
Gaps
______ 1_____
3 (for 24 hour
PHCs; 2 may
be contractual))
1
1
2
2
1
Optional;
vehicles may be
out-sourced
III. Training of personnel during previous (full) year
a.
Available training for________________
Tradition birth attendants
b.
Health Worker (Female)
c.
Aealth Worker (Male)
d.
Medical Officer
e.
Initial and periodic training of paramedics
in treatment of minor ailments
f.
Training of ASHAs___________________
Periodic training of Doctors through
Continuing
Medical
Education,
conferences, skill development training
etc. on emergency obstetric care
3.1.
g-
h.
Training of Health Workers in antenatal
care and skilled birth attendance
i.
Lab Technician______________
Other health workers on RNTCP_______
Number trained
108
IV. Essential Laboratory Services
S.No.
Current
Availability at
PHC
Remarks I Suggestions /
Identified Gaps
Current
Availability at
PHC
If available,
area in Sq.
mts.)
Routine urine, stool and blood tests
4.1.
42?
4.3.
Blood grouping
Bleeding time, clotting time ______________________
Diagnosis of RTI/STDs with wet mounting, grams stain,
etc.
3.4.
Sputum testing for TB
4.5.
4.6.
4.7.
4.8.
4.9.
4.10.
Blood smear examination for malaria parasite
_
Rapid tests for pregnancy_____________ _______ _
RPR test for Syphilis / YAWS surveillance___________
Rapid tests for HIV
____ _________
Others (specify)
V. Physical Infrastructure (As per specifications)
S.No.
Remarks I
Suggestions
/ Identified
Gaps
Where is this PHC located?
5.1.
a.
b.
c.
5.2.
a.
b.
c.
d.
e.
f.
g-
h.
Within Village Locality_________________________________________________
Far from village locality
_____________________________ _
If far from locality specify in km_____________________ ___________________
Building_______________________________ ________ _______________ i—
Is a designated government building available for the
PHC? (Yes/No)
___________
If there is no designated government building, then where does the PHC located
Rented premises____________________________________________________
Other government building__________ __________________________________
Any other specify____________________________________________________
Area of the building (Total area in Sq. mts.)______________________________
What is the present stage of construction of the building
_ __ ______ ___ _
Construction complete___________ _____________________ ______________
Construction incomplete______________________________________________
Compound Wall / Fencing (1 -All around; 2-Partial; 3None)_____________ ________________________________________________
Condition of plaster on walls (1- Well plastered with
plaster intact every where; 2- Plaster coming off in
some places; 3- Plaster coming off in many places or
no plaster)
Condition of floor (1- Floor in good condition; 2- Floor
coming off in some places; 3- Floor coming off in many
places or no proper flooring)
Whether the cleanliness is Good / Fair /
Poor?(Qbserve)________
OPD
109
I.
ii.
iii.
iv.
j-
5.3.
a.
b.
c.
d.
e.
Rooms________________________________________
Wards________________________________________
Toilets________________________________________
Premises (compound)___________________________
Are any of the following close to the PHC? (Observe)
(Yes/No)______________________________________
Garbage dump_________________________________
Cattle shed______________________ ___________ _
Stagnant pool__________________________________
Pollution from industry______ _________________ __
Is boundary wall with gate existing? (Yes / No)_______
Location_______________________________________
Whether located at an easily accessible area?
(Yes/No)____________________
Distance of PHC (in Kms.) from the farthest village in
coverage area
Travel time (in minutes) to reach the PHC from farthest
village in coverage area
Distance of PHC (in Kms.) from the CHC____________
Distance of PHC (in Kms.) from District Hospital______
Prominent display boards regarding service availability
in local language (Yes/No)
Registration counters (Yes/No)
5.4.
5.5.
5.6.
a.
b.
5.7.
5.8.
5.9.
5.10
5.rL
5.12.
5.13.
5.14.
5.15
5.16
5.17.
a.
b.
Pharmacy for drug dispensing and drug storage
(Yes/No)
PHC
to
obtain
Counter near entrance
of
contraceptives, ORS packets, Vitamin A and
Vaccination (Yes / No)
Separate public utilities for males and females
(Yes/No)______________________________________
Suggestion / complaint box (Yes/No)_______________
OPP rooms / cubicles (Yes/No) (Give numbers)______
Adequate no. of windows in the room for light and air in
each room (Yes/No)___________________ _
Family Welfare Clinic (Yes/No)____________________
Waiting room for patients (Yes/No)___________
Emergency Room / Casualty (Yes/No)
Separate wards for males and females (Yes/No)______
No. of beds : Male
____________
No. of beds : Female_________________________
Operation Theatre (if exists)______________________
Operation Theatre available (Yes/No)______________
If operation theatre is present, are surgeries carried out
in the operation theatre?
_
Yes _____________________ __ ______________ _
No
_____________
Sometimes
___________
110
c.
d.
e.
5.18.
a.
b.
c.
d.
5.19.
a.
b.
c.
d.
5.20.
5.21.
a.
b.
c.
d.
5.22
5.23.
5.24.
i If operation theatre is present, but surgeries are not
being conducted there, then what are the reasons for
the same?
______
Non-availability of doctors /staff
Lack of equipment / poor physical state of the
operation theatre________________________________
No power supply in the operation theatre____________
Any other reason (specify)________________________
Operation Theatre used for obstetric / gynaecological
purpose (Yes / No)______________________________
Has OT enough space (Yes / No)______________ __
Labour room
Labour room available? (Yes/ No)__________________
If labour room is present, arc deliveries carried out in
the labour room?________________________________
Yes___________________________________________
No____________________________________________
Sometimes______ ______________________________
If labour room is present. But deliveries are not being
conducted there, then what are the reasons for the
_same?__ ____________________ _________ ________
Non-availability of doctors / staff
_
Poor condition of the labour room__________________
No power supply in the labour room________________
Any other reason (specify)
Is separate areas for septic and aseptic deliveries
available? (Yes / No)____ ________________________
Laboratory:_____________________________________
Laboratory (Yes/No)_______________ _____________
Is the laboratory a RNTCP Designated Microscopy
Centre (PMC) under RNTCP? (Yes/No)_____________
Are adequate equipment (including function Binocular
Microscope) and chemical reagents available?_______
Is laboratory maintained in orderly manner? (Yes / No)
Ancillary Rooms - Nurses rest room (Yes/No)_________
Water supply__________________________________
Source of water (1- Piped; 2- Bore well/ hand pump /
tube well; 3- Well; 4- Other (specify))________________
Whether overhead tank and pump exist (Yes / No)
if overhead tank exist, whether its capacity sufficient?
(Yes/No)_______________________________________
If pump exist, whether it is in working condition? (Yes /
No)_________________________________________
Sewerage
_______________________ __
Type of sewerage system ( 1- Soak pit; 2- Connected
to Municipal Sewerage)___________________________
Waste disposal__________________________________
How the waste material is being disposed (please
specify)?_______________________________________
Electricity
111
a.
b.
c.
5.25.
_a.
b.
5.26.
a.
b.
c.
d.
e.
ti.
iii.
5.27.
Is there electric line in all parts of the PHC? (1- In all
parts; 2- In some parts; 3- None)
Regular Power Supply (1- Continuous Power Supply;
2- Occasional power failure; 3- Power cuts in summer
on'y;
Regular power cuts; 5- No power supply
Stand by facility (generator) available in working
condition (Yes / No)________________________
Laundry facilities:______________________
Laundry facility available(YesZNo)__________________
If no, is it outsourced?___________________________
Communication facilities__________________ _
Telephone (Yes/No)_____________________________
Personal Computer (Yes/No)_____________________
NIC Terminal (Yes/No)___________________________
E-Mail (Yes / No)__________________________ _
Is PHC accessible by
___________________
Rail (Yes / No)______________________________
All whether road (Yes / No)_____________________
Others (Specify)_____________________________
Vehicles____________ __________________________
Vehicle (jeep/other vehicle) available? (Yes / No)
Current
Availability at
PHC
5.28.
5.29.
5.30.
5.31.
a.
b.
5.32.
5.33.
a.
b.
c.
d.
If available,
area in Sq.
mts.)
Remarks I
Suggestions
/ Identified
Gaps
Office room (Yes/No)_______________________
Store room (Yes/No)
Kitchen (Yes / No)_______________________________
Diet:
Diet provided by hospital (Yes/No)_________________
If no, how diet is provided to the indoor patients?
Resident!al facility for the staff with all amenities______
Medical Officer__________________
_
Pharmacist__________________________
Nurses_____________________________________ _
Other staff__________________________________ _
Behavioral Aspects (Yes / No)_____________________
How is the behaviour of the PHC staff with the patient
Courteous
__
__________ ____
Casual/indifferent__________________
Insulting / derogatory __________________________
Any fee for service is charged from the users? (Yes /
No). If yes, specify.
Is there corruption in terms of charging extra money for
any of the service provided? (Yes / No)_____________
Is a receipt always given for the money charged at the
PHC? (Yes / No)
__________________
112
e.
f.
g-
h.
Is there any incidence of any sexual advances? Oral or
physical abuse, sexual harassment by the doctors or
any other paramedical? (Yes / No)_________________
Are woman patients interviewed in an environment that
ensures privacy and dignity? (Yes / No)
Are examinations on woman patients conducted in
presence of a woman attendant, and procedures
conducted under conditions that ensure privacy? (Yes /
No)___________________________________________
Do patients with chronic illnesses receive adequate
care and drugs for the entire duration? (Yes / No)____
i.
If the health centre is unequipped to provide the
services how and where the patient is referred and
how patients transported?
j-
Is there a publicly displayed mechanism, whereby a
complaint/grievance can be registered? (Yes / No)
k.
I.
m.
Is there an outbreak of any of the following diseases in
the PHC area in the last three years?
Malaria_______________________________________ _
Measles_______________________________________
Gastroenteritis__________________________________
Jaundice______________________________________
If yes, did the PHC staff responded immediately to stop
the further spread of the epidment_________________
Does the doctor do private practice during or after the
duty hours? (Yes/ No)
_______________________
n.
Are there instances where patients from particular
social background dalits, minorities, villagers) have
faced derogatory or discriminatory behavior or service
of poorer quality? (Yes / No)
o.
Have patients with specific health problems (HIV/AIDS,
leprosy suffered discrimination in any form? (Yes / No)
VI. Equipment (As per list)
Equipment
Available
Functional
Remarks / Suggestions /
Identified Gaps
VII. Drugs (As per essential drug list)
Drug
Available
Remarks / Suggestions /
Identified Gaps
VIII. Furniture
113
Item
S.No.
8.2.
8.37'
8.4.
8.5.
8.6.
8.7.
8.8.
8.9.
8.10.
8.11.
8.12.
8.13.
8.14.
8.15.
8.16.
8.17.
8.18.
8.19.
8.20.
8.21.
8.22.
8.23.
8.24.
8.25.
8.26^
8.27.
8.28.
8.29.
8.80.
8.31.
8.32.
Current
Availability at
PHC
If available,
numbers
Remarks /
Suggestions
I Identified
Gaps
Examination Table________________
Delivery Table_________________
Footstep________________________
Bed Side Screen______
Stool for patients__________________
Arm board for adult & child__________
Saline stand_____________________
Wheel chair______________ _______
Stretcher on trolley________________
Oxygen trolley____________________
Height measuring stand
________
Iron bed
_____________
Bed side locker___________________
Dressing trolley___________________
Mayo trolley______________________
Instrument cabinet________________
Instrument trolley_________________
Bucket__________________________
Attendant stooj____ __ ___________
Instrument tray___________________
Chair___________________________
Wooden table____________________
Almirah_________________________
Swab rack______________________ _
Mattress________________________
Pillow
____________________ _
Waiting bench for patients / attendants
Medicine cabinet
______________
Side rail
Rack___________________________
Bed side attendant chair___________
Others
IX. Quality Control
S.No.
Particular
9.1.
Citizen's charter (Yes/No)_____________
Constitution of Rogi Kalyan Samiti
(Yes/No) (give a list of office order
notifying the members)_______________
Internal monitoring (Social audit through
Panchayati Raj Institution / Rogi Kalyan
Samitis, medical audit, technical audit,
economic audit, disaster preparedness
audit etc. (Specify)
9.2.
9.3.
Whether functional I available as per
norms
Remarks
114
-
■:
-
115
ANNEX-IV
Proforma for CHCs on IPHS
Identification
Name of the State:
District:
Tehsil/Taluk/Block
Location Name of CMC:
Is This Health Facility Recognized as FRU? (Yes/No)
Date of Data Collection
Day
Month
Year
Name and Signature of the Person Collecting Data
I. Services
S.No.
Population covered (in numbers)
_________
Specialist services available (Yes/No)_________
1.1.
1.2.
Medicine____________ _______
______________________
b. Surgery
______________
c. OBG
d. Pediatrics________________ ______
a.
f.
National Health Programmes (Specify)________
Emergency services (24 Hours)
_
g-
24 - hour delivery services including normal and
assisted deliveries______________
h.
Emergency Obstetric Care including surgical
interventions like Caesarean Sections and other
medical interventions
i.
New-born care
e.
_
Emergency care of sick children
k.
Full range of family planning services including
Laparoscopic Services
I.
Safe abortion services
116
m.
Treatment of STI / RTI
n.
Essential Laboratory Services (Specify the type
of lab tests conducted)____________________
o.
Blood storage facility
P-
Referral transport service
Bed Occupancy Rate in the last 12 months (1less than 40%; 2 - 40-60%; 3 - More than 60%)
1.3.
1.4.
Average daily OPP Attendence
a.
b.
1.5.
1.6.
Male________________ ______ _
Female_________________________________
Types of Surgeries performed (specify)_______
HIV/AIDS_______________ ___ ___________
a.
Availability of Counseling facility on HIV/ AIDS /
STD etc. (Yes/No)
b.
Is it a Voluntary Council and Testing Centre
(VCTC)?
1.7.
a.
b.
c.
1.8.
1.9.
1.10.
1.11.
a.
b.
c.
d.
e.
f.
gh.
Service availability_______________________
Ante-natal Clinics_______________ ________
Post-natal Clinics____________________ •
Immunization Sessions___________________
Number of cases of caeserian delivery (During
last one year)___________________________
Total number of pediatric beds________ _
Is separate septic labour room available
Number of days in a month the services are
available
Availability of facilities for out-patient department
in Gynecology/ obstetric (Yes / No)____________
Board /Name plates to guide the clients_____ _
Adequate working space ___________________
Privacy during examination________ __ ________
Facility for counselling_______________________
Separate toilet with running water___________ _
Facility for Sterilizing instruments______________
Male specialist_____________________________
Female specialist
II.
Manpower
S.No.
Personnel
A.
Clinical Manpower
2.1.
General Surgeon
IPHS Norm
Current
Availability
at CMC
(Indicate
Numbers)
Remarks /
Suggestions
/ Identified
Gaps
1
117
2.2.
Physician
1
2.3.
Obstetrician / Gynaecologist
1
2.4.
Pediatrics
1
2.5.
Anaesthetist
1
2.6.
Public Health Programme Manager
1
2.7.
Eye Surgeon
1
2.8.
2.9.
Other specialists (if any)___________
General duty officers (Medical Officer)
B.
Support Manpower
Personnel
S.No.
IPHS
Norm
Nursing Staff
7+2
a.
Public Health Nurse
1
b.
ANM
1
C.
Staff Nurse
Tlurse/Midwife__________
7
2.11.
2.12
2.13.
2.14.
Dresser_______________
2
Pharmacist / compounder
1
2.15.
Ophthalmic Assistant
1
2.16.
Ward boys / nursing orderly
2
2.10.
d7
Lab. Technician_______
Radiographer__________
Current
Availability
atCHC
(Numbers)
On
contractual
appointment
or hiring of
services from
private
sectors on
case to case
basis_______
On
contractual
appointment
For every 5
lakh
population as
per vision
2020
approved
Plan of
Action
Remarks / Suggestions I
Identified Gaps
1 ANM and 1 Public Health
Nurse for family welfare will
be appointed under the
ASHA scheme
_______
7
1
Ophthalmic Assistant may
be placed wherever it does
not exist through
redeployment or contract
basis
118
2.17.
2.18.
2.19.
2.20.
2.21.
2.22.
2.23.
c.
Training of MOs during previous (full) year
2.24
Available training in
Sweepers_________________________
Chowkidar_________________________
3
OPP Attendant_______________ _____
£
Statistical Assistant / Data entry operator
1
OT Attendant______ _ _____ ________
Registration Clerk___________________
Any other staff (specify)
7
Flexibility may rest with the
State for recruitment of
personnel as per needs
1
Number of MOs trained
a.
Sterilization
b.
IUD Insertions
c.
Emergency contraception
d.
RTI/STI, HIV/ AIDS
e.
Newborn care
f.
Emergency obstetric care
9-
Other subjects (mention)
h.
Training of Medical Officers on RNTCP
III. Investigative Facilities
IPHS Norm
S.No.
3.1.
Availability of ECG facilities (Yes / No)
32?
X-Ray facility (Yes / No)
Ultrasound facility (Yes / No)
3.3.
3.4.
Appropriate training to a nursing staff on ECG (Yes / No)
3.5.
Lab test facilities (specify kind of tests done)
3.6.
Any lab test / diagnostic test outsourced to private lab /
hospital (please specify the test)
3.7.
All necessary reagents, glassware and facilities for
collection and transportation of samples (Yes / No)
Current
Availability
atCHC
Remarks / Suggestions /
Identified Gaps
Current
Availability
at CMC
If
available,
area in Sq.
mts.)
IV. Physical Infrastructure (As per specifications)
S.No.
Where is this CMC located?
4.1.
a.
b.
c.
4,2.
Remarks I
Suggestions
/ Identified
Gaps
Within Village Locality_______
Far from village locality
___
If far from locality specify in km
Building___________________
119
a.
b.
c.
d.
e.
Condition of plaster on walls (1- Well plastered with
plaster intact every where; 2- Plaster coming off in some
places; 3- Plaster coming off in many places or no plaster)
g-
Condition of floor (1- Floor in good condition; 2- Floor
coming off in some places; 3- Floor coming off in many
places or no proper flooring)
I.
ii.
iii.
iv.
4.3.
a.
b.
c.
4.4.
a.
b.
c.
4.6.
4.7.
If there is no designated government building, then where does the CHC located
Rented premises__________________ _______________ __________________
Other government building____________________________________________
Any other specify______________________________________________
Area of the building (Total area in Sq. mts.)_____________ _________________
What is the present stage of construction of the building
Construction complete________________________________________________
Construction incomplete_______________ ____ _____ _______________ _
Compound Wall / Fencing (1 -All around; 2-Partial; 3None)_________________ _____________________________________________
f.
h.
4.5.
Is a designated government building available for the
CHC? (Yes / No)
Whether the cleanliness is Good / Fair / Poor?(Observe)
' OPP____________________________________________
' OT______________________________________________
Rooms__________________________________________
Wards___________________________________________
Toilets____________________________ _ __________
Premises (compound)______________________________
Are any of the following close to the hospital? (Observe)
(Yes/No)
Garbage dump____________________________________
Cattle shed_______________________________________
Stagnant pool_____________________________________
Pollution from industry______________________________
Location_________________________________________
Whether located at less than 2 hours of travel distance
from the farthest village? (Yes/No)
Whether the district head quarter hospital located at a
distance of less than 4 hours travel time? (Yes/No)
Feasibility to hold the workforce (e.g. availability of degree
college, railway station, municipality, industrial/mining
belt) (Yes/No) (specify)
Availability of Private_Sector Health Facility in the area ___
Private laboratory/hospital/Nursing Home (Yes/No)______
Charitable Hospital (Yes/No) (specify)_________________
Hospital run by NGQ (Yes/No)______________ ________
Prominent display boards in local language / Charter of
Patient Rights (Yes/No)_____________________________
Registration counters (Yes/No)
120
a.
b.
4.8.
4.9.
4.10.
4.11.
4.12.
4.13.
4.14.
4.15.
4.16.
4.17.
4.18.
a.
b.
c.
d.
e.
f.
gh.
h
k.
4.19.
Pharmacy for drug dispensing and drug storage (Yes/No)
Counter near entrance of hospital to obtain contraceptives, ORS
packets, Vitamin A and Vaccination (Yes / No) ______ _
Separate public utilities for males and females (Yes/No)
Suggestion / complaint box (Yes/No)_________________
OPP rooms / cubicles (Yes/No) (Give numbers)
Adequate no. of windows in the room for light and air in
each room (Yes/No)_______________________________
Family Welfare Clinic (Yes/No)_______________________
Waiting room for patients (Yes/No)___________________
Emergency Room / Casualty (Yes/No)
__________ _
Separate wards for males and females (Yes/No)________
No. of beds : Male_________________________________
No. of beds : Female
Operation Theatre_________________________________
Operation Theatre available (Yes/No)_________________
If operation theatre is present, are surgeries carried out in
the operation theatre?
Yes_________________________________________ ___
_Nq______________________________________________
Sometimes
If operation theatre is present, but surgeries are not being
conducted there, then what are the reasons for the same?
Non-availability of doctors / anaesthetist / staff__________
Lack of equipment / poor physical state of the operation
theatre_______________________________________
No power supply in the operation theatre_______________
Any other reason (specify)___________ _ _______ __ ___
Operation Theatre used for obstetric / gynaecological
purpose (Yes / No)________________________________
Has OT enough space (Yes / No)_____________________
Is OT fitted with air conditioner? (Yes / No)
Is the air conditioner working? (Yes / No)
Is generator available for OT? (Yes / No)_______________
Is emergency light available in OT? (Yes / No)
Is fumigation done regularly? (Yes / No)_______________
Is the days of sterilization in a week displayed on the
public notice on OT? (Yes / No)
Operation Theatre Equipment
Available
(Yes/No)
Working
(Yes/No)
Boyles apparatus
EMO Machine
Cardiac Monitor for OT
Defibrillator for OT
Ventilator for OT
Horizontal High Pressure Sterilizer
Vertical High Pressure sterilizer 2/3 drum capacity
121
Shadowless lamp ceiling trek mounted
Shadowless lamp pedestal for minor OT
OT care / fumigation apparatus
Gloves & dusting machines
Oxygen cylinder 660 Ltrs 10 cylinders for 1 Boyles
Apparatus_______________________ _________________
Nitrous Oxide Cylinder 1780 Ltr. 8 for one Boyles
Apparatus
______________________
_______
Hydraulic Operation Table
4.20.
a.
b.
c.
4.21.
4.22.
a.
b.
c.
d.
4.23.
Labour room
__
Labour room available? (Yes/ No)
____
_
________
If labour room is present, arc deliveries carried out in the
labour room?_________________________ __ _________
Yes_______________________________ _
No
Sometimes_______________________
If labour room is present. But deliveries are not being
conducted there, then what are the reasons for the same?
Non-availability of doctors / staff______________________
Seepage in the labour room_________________________
No power supply in the labour room
________________
Any other reason (specify)
..........
X-ray room with dark room facility (Yes/No)
Laboratory:
_________________________________
Laboratory (Yes/No)__________________
_____
Is the laboratory a RNTCP Designated Microscopy Centre
(PMC) under RNTCP? (Yes/No)_____________________
Are adequate equipment (including function Binocular
Microscope) and chemical reagents available?
Is laboratory maintained in orderly manner? (Yes / No)
Cold Chain
a.
b.
c.
d.
e.
4.24.
a.
b.
c.
4.25.
4.26.
a.
b.
Available?
In working
condition?
Walk-in coolers (Yes / No)___________________________
Walk-in freezers available (Yes / No)__________________
Icelined freezers (Yes / No)
__________
Deep freezers (Yes / No)
_______________________
Refrigerators (Yes / No)____________________________
Blood Storage Unit__________________________
Blood Storage Unit available(YesZNo)_________________
Is the CMC having linkage with district blood bank? (Yes /
No)_________________________________________ ____
Is regular blood supply available? (Yes / No)
Ancillary Rooms - Nurses rest room (Yes/No)
____
Water supply________________________
Source of water (1- Piped; 2- Bore well/ hand pump / tube
well; 3- Well; 4- Other (specify))_________________
Whether overhead tank and pump exist (Yes / No)
122
c.
d.
4.27.
4.28.
a.
b.
c.
4.29.
a.
If overhead tank exist, whether its capacity sufficient?
(Yes/No)_________________________________________
If pump exist, whether it is in working condition? (Yes /
No)
Sewerage ______________________________________
Type of sewerage system ( 1- Soak pit; 2- Connected to
Municipal Sewerage)
______ _______
Waste disposal____________________________________
Is there an incinerator? (Yes / No)
If yes, type (1- electric; 2- Other (specify)
If no, how the medical waste disposed off?_____________
Electricity___________________ _______ _____________
Is there electric line in all parts of the hospital? (1- In all
parts; 2- In some parts; 3- None)
b.
Regular Power Supply (1- Continuous Power Supply; 2Occasional power failure; 3- Power cuts in summer only;
4- Regular power cuts; 5- No power supply_____________
c.
Stand by facility (generator) available (Yes / No)
a.
b.
Laundry facilities:
Laundry facility available(Yes/No)____________________
If no, is it outsourced?
a.
Communication facilities
________ _
Telephone (Yes/No)____________________
4.30.
4.31.
b.
Number of different telephone lines available
c.
Personal Computer (Yes/No)____ _
NIC Terminal (Yes/No)__________________
E-Mail (Yes / No)_______________________
Is CHC accessible by
Rail (Yes / No)_________________________
All whether road (Yes / No)______________
Others (Specify) _____________ _______
Vehicles
If running
Ambulance
Jeep__
Car
If vehicle is not running
d.
e.
f.
ii.
iii.
4.32.
a.
b.
_________ Number of Vehicles
Sanctioned
On road
Available
Driver not
available
Reason
Money for
POL not
available
Money for
repairs not
available
Ambulance
Jeep_____
Car
123
Current
Availability
atCHC
4.33.
4.34.
4.35?
4.36.
a.
Office room (Yes/No)___________
Store room (Yes/No)___________
Kitchen (Yes / No)_____________
Diet:________________________
Diet provided by hospital (Yes/No)
b.
If no, how diet is provided to the indoor patients?
4.37.
4.38.
a.
b.
c.
If
available,
area in Sq.
mts.)
Remarks /
Suggestions
/ Identified
Gaps
Residential facility for the staff with living condition
General Surgeon___________________________
Physician_________________________________
Obstetrician / Gynaecologist__________________
Paediatrics________________________________
Anaesthetist_______ ________________________
General Duty Medical Officer_________________
Public Health Programme Manager____________
Eye Surgeon______________________________
Public Health Nurse_________________________
ANM_____________________________________
Staff Nurse_________ _ ____________________
Nurse/Midwife_____________________________
Dresser___________________________________
Pharmacist / compounder____________________
Lab. Technician_____________________ ____ _
Radiographer______________________________
Ophthalmic Assistant_____________________
Ward boys / nursing orderIy__________________
Sweepers_________________________________
Chowkidar________________________________
OPD Attendant_______ ______________ ___ ___
Statistical Assistant / Data entry operator_______
OT Attendant______________________________
Ambulance driver______ _ __________________
Registration Clerk__________________________
Accommodation facility for families of admitted
patients___________________________________
Facility for stay available (Yes / No)____________
Attached toilet available (Yes / No)_____________
Cooking facility available (Yes / No)
4.39.
a.
b.
Is the CHC open for outpatient services for the stipulated
OPD time?
Yes, on all days excepting designated holidays_________
No, it always closes before time______________________
Only on some days it functions for the stipulated time
If yes, specify stipulated OPD hours
124
In cases where a patient needs to be admitted for
inpatient care, is he/she admitted?____________________
Yes, patients who can be managed at CHC are always
admitted
4.40
Some deserving patients are not admitted but are referred
to other facilities
Patients usually refused admission
Does the CHC provide treatment to emergency patients
/victims of accident medical emergencies etc) at any time
of the day/ night?
4.41.
Emergency patients are given treatment. Where
necessary, they are referred higher level Govt, hospital
Emergency patients are often not treated, referred to a
public health care facility
Emergency patients are often not treated, referred to a
private health care facility
If referred to a higher-level health care facility, how is the
patient taken there?
4.42.
Free transport by hospital ambulance
By hospital ambulance, but fuel and other charges have to
be made by the patient
Private/ personal conveyance
4.43.
a.
b.
Behavioral Aspects________________________________
How is the behaviour of the CHC staff with the patient
Courteous________________________________________
Casual/indifferent_________________
Insulting / derogatory_______________________________
Is there corruption in terms of charging extra money for
any of the service provided? (Yes / No)________________
c.
Is a receipt always given for the money charged at the
CHC? (Yes/No)
d.
Is there any incidence of any sexual advances? Oral or
physical abuse, sexual harassment by the doctors or any
other paramedical? (Yes / No)
e.
Are woman patients interviewed in an environment that
ensures privacy and dignity? (Yes / No)
f.
Are examinations on woman patients conducted in
presence of a woman attendant, and procedures
conducted under conditions that ensure privacy? (Yes /
No)
g.
Do patients with chronic illnesses receive adequate care
and drugs for the entire duration? (Yes / No)
h.
If the health centre is unequipped to provide the services
needed, are patients transferred immediately without
delay, with all the relevant papers, to a site where the
desired service is available? (Yes / No)
125
I.
Is there a publicly displayed mechanism, whereby a
complaint/grievance can be registered? (Yes / No)
V (A). Equipment (As per list)
Equipment
Available
Functional
Remarks / Suggestions I
Identified Gaps
V (B). Drugs (As per essential drug list)
Remarks / Suggestions I
Identified Gaps
Available
Drug
VI. Furniture
S.No.
6.1.
6.2.
6.3.
64.
6.5. '
6.6.
6.7.
6.8.
6.9.
6.10.
6.11.
6.12. "
6.13.
6.14.
6.15.
6.16.
ML
6/I8.
6.19.
Item
Current
Availability
at CMC
If
available,
numbers
Remarks I
Suggestions
I Identified
Gaps
Examination Table
Delivery Table__________
Footstep
Bed Side Screen________
Stool for patients
Arm board for adult & child
Saline stand __________
Wheel chair_________
Stretcher on trolley
Oxygen trolley
Height measuring stand
Iron bed_______________
Bed side locker_________
Dressing trolley
Mayo trolley_______ _
Instrument cabinet
Instrument trolley_______
Bucket______________
Attendant stool
_
126
6.20.
6.21.
6.22.
Instrument tray
Chair____________________________________
Wooden table________________________ _
Almirah
6.23.
6.24.
Swab rack________________________________
Mattress_________________________________
6.25.
6.26. __ Pillow __________________________________
6.277
J/yajtingbenc^^
6.28.
Medicine cabinet___________________________
Side rail__________________________________
6.29.
Rack
6.30.
Bed side attendant chair
6.31.
VII. Quality Control
S.No.
Particular
7.1.
Citizen's charter (Yes/No)
Constitution of Rogi Kalyan Samiti (Yes/No)
(give a list of office order notifying the members)
7.2.
7.3.
7.4.
7X
Whether functional / available as
.per norms
Remarks
Internal monitoring (Social audit through
Panchayati Raj Institution Z Rogi Kalyan Samitis,
medical audit, technical audit, economic audit,
disaster preparedness audit etc. (Specify)_______
External monitoring (Gradation by PRI (Zila
Parishad)/ Rogi Kalyan Samitis_______________
Availability of Standard Operating Procedures
(SOP) / Standard Treatment Protocols (STP)/
Guidelines (Please provide a list)
127
ANNEX-V
REFERENCE DOCUMENTS
1. RCH Phase II - National Programme Implementation Plan (2005-2012), Ministry of Health &
Family Welfare, Government of India (Document and CD available)
2. National Rural Health Mission (2005-2012) - Guidelines for Operationalizing Support Mechanism
for ASHA 2006, Training Division, Department of Family Welfare, Ministry of Health & Family
Welfare, Government of India
3. National Rural Health Mission (2005-2012) - Mission Document, Ministry of Health & Family
Welfare, Government of India
http://www.mohfw.nic.in/NRHM%20Mission%20Document.pdf
4. ACCREDITED SOCIAL HEALTH ACTIVIST (ASHA) Guidelines, Ministry of Health & Family
Welfare, Government of India
http://www.mohfw.nic.in/eaq/accredited social health activis.htm
5.
Reading Material for ASHA- Book No. 1, Ministry of Health & Family Welfare, Government of India
6.
Facilitators Guide for ASHA- Book No. 1, Ministry of Health & Family Welfare, Government of India
7. National Rural Health Mission (2005-2012), Frequently Asked Questions, Ministry of Health &
Family Welfare, Government of India
http://mohfw.nic.in/Frequentlv%20Asked%20Questions-March%2022,%202005.pdf
8<lndian Public Health Standards (IPHS) for CHC - Draft Guidelines, Directorate General of Health
Services, Ministry of Health & Family Welfare, Government of India
http://www.mohfw.nic.in/draft%20chc%208march final.pdf
9. / Indian Public Health Standards (IPHS) for PHC - Guidelines, March 2006, Directorate General of
Health Services, Ministry of Health & Family Welfare, Government of India
http://www.mohfw.nic.in/IPHS%20for%20PHC%20 04.April.2006 .pdf
10. Indian Public Health Standards (IPHS) for SUB-CENTRES - Guidelines, March 2006, Directorate
General of Health Services, Ministry of Health & Family Welfare, Government of India
http://www.mohfw.nic.in/IPHS%20for%20SUB-CENTRES%20 07%20April%202006 .pdf
IXOanani Suraksha Yojana - Guidelines for Implementation
http://www.mohfw.nic.in/layout 09-Q6.pdf
12 (^idefinesforconstittifimc^^
http://www.mohfw.nic.in/Guidelines%20for%20Settinq%20up%20Roqi%20Kalyan%20Samitis.ht_m
13. Implementation Guide on ROH II - Adolescent Reproductive Sexual Health Strategy for State and
District Programme Manager, May 2006, Ministry of Health & Family Welfare, Government of India
128
14. Efficient Management of Community Health Centre, Rajasthan
http://www.prod-india.com/searnum.asp?PNum=14Q
15. Good Practices
16. Letter of Mr. P. K. Hota, Secretary (FW), Government of India, Department of Family Welfare,
Government of India regarding District Programme Management Units
129
ANNEX-VI
TIME LINE FOR NRHM ACTIVITIES
Phasing and time
______ line______
Fully trained Accredited Social Health 50% by 2007
Activist
(ASHA)
for
every
1000 100% by 2008
population/large isolated habitations.
Activity
1
Outcome
Monitoring
Quarterly
Progress Report
2
Village Health and Sanitation Committee
constituted in over 6 lakh villages and
untied grants provided to them.
30% by 2007
100% by 2008
Quarterly
Progress Report
3
Centres
2
ANM
Sub
Health
provide
to
strengthened/established
service guarantees as per IPHS, in
1,75000 places.
30% by 2007
60% by 2009
100% by 2010
Annual Facility
Surveys
External
assessments
4
30,000 PHCs strengthened/established
with 3 Staff Nurses to provide service
guarantees as per IPHS.
30% by 2007
60% by 2009
100% by 2010
5
6500 CHCs strengthened/established
with 7 Specialists and 9 Staff Nurses to
provide service guarantees as per IPHS.
30% by 2007
50% by 2009
100% by 2010
6
1800 Taluka/ Sub Divisional Hospitals
strengthened to provide quality health
services.
30% by 2007
100% by 2010
7
600 District Hospitals strengthened to
provide quality health services.
30% by 2007
60% by 2009
100% by 2010
8
Rogi
Kalyan
Samitis/Hospital
Development Committees established in
all CHCs/Sub Divisional Hospitals/ District
Hospitals._____________ _____________
District Health Action Plan 2005-2012
prepared by each district of the country.
50% by 2007
100% by 2009
Untied grants provided to each Village
Health and Sanitation Committee, Sub
Centre, PHC, CHC to promote local
health action.
50% by 2007
100% by 2008
Annual Facility
Surveys
External
assessments
Annual Facility
Surveys.
External
assessments.
Annual Facility
Surveys.
External
assessments.
Annual Facility
Surveys.
External
assessments.
Annual Facility
Surveys.
External
assessments.
Appraisal
process.
External
assessment.
Independent
assessments.
Quarterly
Progress reports.
9
10
50% by 2007
100% by 2008
130
12 State
50% by 2007
100% by 2008
Independent
assessments.
Quarterly
Progress
Reports.
Independent
assessment.
13
50% by 2007
100% by 2008.
50% by 2007
100% by 2008.
Independent
assessment.
External
assessment.
30% by 2007
50% by 2008
70% by 2009
100% by 2010
Annual Facility
Surveys.
Independent
assessments.
30% by 2007
60% by 2008
100% by 2009
Appraisal
process.
Independent
assessment.
50% by 2007
100% by 2008
Independent
assessment.
30% by 2008
60% by 2009
100% by 2010.
Institution-wise
assessment
of 30% by 2008
performance against assured service 60% by 2009
guarantees carried out.________________ 100% by 2010.
Mobile Medical Units provided to each 30% by 2007
60% by 2008
district of the country.
100% by 2009.
Independent
assessment.
11
14
15
16>
17
18
19
20
Annual maintenance grant provided to
every Sub Centre, PHC, CHC and one
time support to RKSs at Sub Divisional/
District Hospitals.
and
District Health Society
established and fully functional with
requisite management skills.___________
Systems of community monitoring put in
place.______________________________
Procurement and logistics streamlined to
ensure availability of drugs and medicines
at Sub Centres/PHCs/ CHCs.__________
SHCs/PHCs/CHCs/Sub
Divisional
Hospitals/ District Hospitals fully equipped
tp
develop
intra
health
sector
convergence, coordination and service
guarantees for family welfare, vector
borne
disease
programmes,
TB,
HQV/AIDS, etc.______________________
District
Health
Plan
reflects
the
convergence with wider determinants of
health like drinking water, sanitation,
women’s
empowerment,
child
development,
adolescents,
school
education, female literacy, etc.
Facility and household surveys carried
out in each and every district of the
country.____________________________
Annual State and District specific Public
Report on Health published
50% by 2007
100% by 2008
Independent
assessment.
Quarterly
Progress Report.
131
ANNEX-VII
DELEGATION OF ADMINISTRATIVE AND FINANCIAL POWERS
KeyActivTt>e&Fi>x^ions
Delegation of administrative and
financial powers required for
effectiveness
Level
1. Village level
Constitution and capacity development of
Village Health and Sanitation Committee,
appointment of ASHA with co-terminality
with ICDS, School Health Programme,
untied grants for local action, household
surveys,
availability
of
drugs,
establishment
of
referral
chains,
organization of campaigns for cleanliness
and behaviour change, organizing Village
Health Day at the ICDS center, setting up
of
revolving
fund,
performance
assessment
of
of
ASHA,
convergence/merger
with
other
Committees, availability of JSY resources
for
institutional
deliveries,
immunization/other
campaigns,
development of local plans, etc.
1. Issue of implementation framework of the
NRHM by Government of India to States,
clearly stipulating the setting up of Village
Health and Sanitation Committees by
merger/fresh constitution, detailing the
funds to be made available to these
Committees, activities to be taken up from
these resources, and specifying the
process to be used for maintaining
accounts of the VHSC, its audit, submission
of utilization certificates, etc.
consolidated
2.
Issue
of
detailed
instructions by the State Government
specifying membership of VHSC, its
integration with PRIs, process of its
constitution, its account keeping and
cheque signing powers, system of
maintaining records, social/financial audit of
funds, role in decentralized planning for
health, convergence with other departments
at the village level, etc. This instruction is
best issued at the level of the Development
Commissioner in consultation with the
Panchayati Raj, Women and Child, School
Education, Drinking water and Sanitation
Departments, etc.
3. Time bound direction to districts for
actual constitution of these committees,
their training, selection of ASHAs, co
location of ASHA at the ICDS center,
transfer of untied funds, etc.____________ _
2. Gram Panchayat/
SHC level
Constitution
of SHC
level
Gram
Panchayat Committee with representation
to VHSCs, appointment of second ANM
on local criteria and by local government
against specific vacancy, opening of joint
account of Sarpanch and ANM for untied
funds for local health action and repair
and maintenance, identification of Rural
Medical Practitioners for skill upgradation,
immunization campaigns, drug availability
as
per
local
need,
ANC/PNC,
maintenance of accounts of performance
based payments, JSY, etc.
1.
Finalization
of
Framework
for
Implementation of NRHM by Department of
Health and Family Welfare, clearly spelling
out the constitution
of SHC/Gram
Panchayat level Committee, its powers,
functions, system of selection of additional
AN Ms on local criteria, resources to be
made available to Gram Panchayats, their
account keeping and audit, etc.
2.
Issue
of
detailed
consolidated
instructions by State Governments on the
role, power, functions, membership of the
Gram Panchayat/SHC level Committees, its
systems of account keeping, audit and
record maintenance.
3. Issue of direction to districts to comply
with formation and follow up in a time
bound manner.
132
3. PHC/Cluster of
Panchayat levels
Setting up PHC level Panchayat led Rogi
Kalyan Samiti, appointment of two
additional Staff Nurses on local criteria,
24X7 emergencies that could be attended
by Nurses, co-location of AYUSH doctors,
Posting of Medical Officers based on
State’s vision for that PHC, availability of
drugs, key diagnostic tests, paramedic
staff/facilities,
provision
of
labour
room/Normal deliveries, key point for
national health programmes, etc.
1.
Finalization
of
Framework
for
Implementation of NRHM by Department of
Health and Family Welfare, clearly spelling
out the constitution of PHC/Cluster level
Committee, its powers, functions, system of
selection of Staff Nurses on local criteria,
resources to be made available to the
PHC/Cluster, their account keeping and
audit, etc.
2.
Issue
of
detailed
consolidated
instructions by State Governments on the
role, power, functions, membership of the
PHC/Cluster level Committees, its systems
of account keeping, audit and record
maintenance.
3. Issue of direction to districts to comply
with formation and follow up in a time
bound manner.
4.
Block
Panchayat
level
CHCZ
Samiti
5. District Mission/
Zila Parishad level
Creating a Block level Public Health
Team, supervising the network of health
functionaries,
amalgamating
primary,
secondary and tertiary care, integration of
AYUSH, developing effective systems of
distribution of supplies, supervising
referral linkages, preparing Block level
Health Plans, organizing community
action, providing 24X7 Hospital services at
Block level, training and skill development
of community organizations/PRIs, ASHAs,
ICDS workers, skill development of ANMs,
Nurses, etc, conducting Facility Surveys,
accrediting private providers for public
health goals, setting up Block Resource
Group, first level for integration of MIS/
Monitoring and evaluation, setting up of
Block level Monitoring Group, constitution
of RKS for the Block Hospital, Panchayat
Samiti Committee for Block Health Plan
and its implementation.
Responsible for planning, implementing,
monitoring and evaluating progress of
Mission, preparation of Annual Work
Plans and Budgets, suggesting district
specific innovations, partnerships with
PRIs, NGOs, strengthening training
institutions for ANMs/ Para Medic
functionaries, provide leadership to
village, Gram Panchayat, Cluster and
Block level Teams, establish District
Resource Group for capacity building ,
fully operationalize District Hospital to
IPHS, experiment with risk pooling, ensure
referral chain and timely disbursal of
claims, arrange for technical support as
per need, nurture community processes,
establish
transparent
systems
of
procurement and logistics, set up
financial,
programme,
and
data
management
teams
to
improve
1. Issue of implementation framework for
NRHM by Department of Health and Family
Welfare, mandating a clear role for Block
level Management of the Mission, under the
umbrella of Panchayati Raj Institutions.
2.
Issue
of detailed
consolidated
instructions by the State Government on
constitution
of
Block
level
Health
Committee, Rogi Kalyan Samiti, etc.,
specifying specific procedures to be
followed, composition of the Block level
Health Management Mission, its staffing,
etc.
3. Direction to districts to constitute and
assign funds, functions and functionaries to
Block level Panchayati Raj Institutions in a
time bound way.
4. Setting up of Block level management
team and resource group to meet
managerial and capacity development
challenges.
1. Issue of implementation framework for
NRHM by Department of Health and Family
Welfare, mandating a clear role for District
level Management of the Mission, under the
umbrella of Panchayati Raj Institutions.
2.
Issue
of
detailed
consolidated
instructions by the State Government on
constitution of District / Zila Parishad level
Health Committee, Rogi Kalyan Samiti, etc.,
specifying specific procedures to be
followed, composition of the District level
Health Management Mission, its staffing,
etc.
3. Direction to districts to constitute and
assign funds, functions and functionaries at
district level under the umbrella of the Zila
Parishad in a time bound way.
133
management of an accountable health
system, carry out health facility surveys
and
supervise
household
surveys,
Develop District Health Action Plan under
the umbrella of the Zila Parishad for
convergent action, coordination with wider
determinants of health, etc.____________
6.
State
Health
Mission level
7.National Health
Mission level
4. Clear constitution of District level Health
Mission and the District Resource Group for
improved management and capacity
building.
To provide support to District Health 1. Setting up of the State level Health
Missions as per need, to provide capacity Mission with skills needed to carry out the
development support at all levels through functions assigned to it by deputation, re
the State Health System Resource deployment and infusion of new skills
Centre, SIHFW, RRCs, etc. , to develop wherever required.
planning and implementation norms in line
with the National level implementation 2. Setting up approval and appraisal
framework for NRHM< to release committees/bodies as required.
resources to districts and meet auditing
and accounting standards, to engage 3. Setting up Grants in Aid Committees for
professionals, NGOs, as per need to consideration of NGO proposals.
ensure that the finest human resource
meet the needs of the Mission, to guide 4. Laying down clear administrative and
and train health teams at all levels, to get financial responsibilities at every level.
independent
studies
conducted,
to
establish transparent, timely and quality 5. Issuing clear guidelines for decentralized
procurement procedures, to finalize district level planning and implementation.
formats for surveys, and reports and
ensure their timely submission, to 6. Set up the State level Health System
converge with other departments and Resource Centre to provide support for
seek
facilitating
administrative capacity development by hand-holding
instructions, to involve non governmental wherever required.
providers and develop models for risk
pooling.
To provide a broad framework for
implementation, to extend support for
capacity development through the NIHFW
and the National Health Systems
Resource Centre, to appraise and
approve District and State Health Action
Plans and their Annual Work Plans and
Budgets, in partnership with States, to lay
down broad parameters for periodic
assessment, to set Indian Public Health
Standards and to monitor against agreed
bench marks, to ensure a rigorous
process of appraisal and approval that
allows for need based local health action,
to set broad framework for risk pooling,
non governmental partnership, to develop
appropriate management structures for
improved service delivery, to push
decentralization,
delegation
and
devolution of funds, functions and
functionaries within the Panchayati Raj
framework, to provide leadership to States
wherever required on technical matters, to
involve institutions of excellence in
building management capacities for
improved health care delivery, and to
engage with the process of skill
development at all levels._____________
1. Issue of clearly articulated Framework for
Implementation to facilitate delegation and
decentralization of powers and functions.
2. Constitution of the NPCC, EPC, MSG to
carry out its responsibilities with regard to
appraisal and approval of proposals.
3. Set up the National Health Systems
resource Centre as a registered society to
provide support for capacity building at all
levels.
4. Develop framework for monitoring,
mentoring, independent evaluation, HMIS,
human
resource
planning,
financial
guidelines, system of account keeping,
audit, etc.
134
ANNEX-VIII
MONITORING FORMAT FOR NRHM
NATIONAL RURAL HEALTH MISSION
STATUS AS ON
Action Point
Sno
Administrative structure of the state
1
Rural Population
2
No.of Districts
3
Number of Blocks
4
Number of Villages
Rural Health Infrastructure
5
Number of District Hospitals
6
Number of Sub Div. Hospitals
Available as on date
7
No. of CHCs
Requirement
Available as on date
J
No. of PHCs
Requirement
No. of Subcentres
Available as on date
9
No. of SCs
Requirement
135
Institutional Framework of NRHM
10
11
12
13
Organogram of Mission Directorate at State and District level
Number of meetings of State Health Mission held till date during 2006-07
Total Number of meetings of District Health Missions held till date during 2006-07
Contact details of Mission Director
State level Y/N
14
Merger of Societies
No of Districts
DH level
CHCs
13
No. of Rogi Kalyan Samitis registered
PHCs
15
Moll with Government of India signed
136
Appointment of ASHA
16
Total num of ASHA to be selected over the Mission period
.7
No. of ASHA selected during 2005-06
Target
8
No. of ASHA selected during 2006-07
Achieved
19
Training Calendar of ASHA finalised (Y/N)
2005-06
1st module
2006-07
Number of ASHA s who have received
training
2nd module
90
3rd module
4th module
Sth module
21
Number of ASHAs who are in position with drug kits
Target
2
Total Num of Monthly Health Days held till date in the state during
2006-07
Achieved
137
Infrastructure & Manpower
>
Centres
23
No. of SCs which are functional with an ANM and Joint account with Pradhan has been
operationalsied.
24
No. of SCs where there are two ANMs positioned
25
%of Subcentres which have submitted UC for untied funds released during 2005-06
’rimary Health Centres (PHCs)
26
Total No. of PHCs functioning on 24x7 basis as on 31/3/2004
27
No. of PHCs made functional on 24x7 basis during 2005-06
28
No. of PHCs expected to be made functional on 24x7 basis during 200607
Target
Achieved
29
No. of PHCs where AYUSH practitioners have been co located during
2005-06
Target
Achieved
Target
30
No. of PHCs where AYUSH practitioners are being co located during
2006-07
Achieved
31
No. of PHCs where three staff nurses are positioned
138
•
Total No. of CHCs selected for upgradation to IRKS
)2
Total No. of CHCs where facility survey has been completed
Identified
Number of CHCs where physical upgradation work has been taken
up
o4
Started
Completed
....... ........................................................................... .
st Referral Units (FRUs)
I
c
Sub Div Hospital
Number of FRUs working as on 31/3/2004
6
CHC
7
:
■
PHC
Sub Div Hospital
'6
Number of centres upgraded as FRUs during 2005-06
CHC
PHC
Target
Sub Div Hospital
Achieved
°7
Number of centres to be upgraded as FRUs
during 2006-07
Target
CHC
Achieved
Target
PHC
Achieved
139
Availability of Consumables
CHCs
38
PHCs
% of centres with at least two month supply of essential drugs
SCs
CHCs
39
PHCs
% of centres with at least two month supply of vaccines
SCs
CHCs
40
PHCs
% of centres with at least two month supply of contraceptives
SCs
Manpower
Target
Specialist
Achieved
Target
Doctors
Achieved
Target
41
Number of contractual manpower
positioned during 2006-07
SN
Achieved
Target
ANM
Achieved
Target
Others
Achieved
42
Programme Management Unit set up at State level (Y/N)
43
Number of Districts where PMU set up
Accounts
Number of Districts where the PMU has
persons from
Managerial
MIS
44
Number of Blocks where PMU set up
140
ii
■5
■6
Institutional Delivery
Number of Institutional Deliveries during 2005-06
No.of beneficiaries of JSY
(2005-06)
Target
r?
Number of Institutional Deliveries expected during 2006-07
Achieved
Target
48
No.of beneficiaries of JSY expected 2006-07)
Achieved
Target
49
No.of pvt institutions accredited under JSY
Achieved
Decentralised Planning
#
Date by when Perspective State Action Plan under NRHM shall be finalised for Mission
Period
111
1
Date by when Annual State Action Plan under NRHM shall be finalised for 2006-07
"2
Number of Districts where Annual Integrated District Action Plan under NRHM prepared for
06-07
___
Funds released to the States for JSY (Rs. In Lakh)
141
Num of Districts where AD syringes
53
Number of Districts where mobile medical units are working
54
No. of Health Mela held during 2005-06
Target
55
No. of Health Mela to be held during 2006-07
Achieved
Target
56
No. of beneficiaries of Male Sterlisation 2006-07
57
No. of beneficiaries of Female Sterlisation 2006-07
Achieved
Target
58
Total number of MNGOs in the state as on 31-3-2004
59
Number of MNGOs Selected during 2005-06
Achieved
Target
60
Number of MNGOs Selected during 2006-07
Achieved
61
Funds released for selection of MNGOs during 2006-07
A
-
142
Financial Matters
L
Financial Reporting during 2005-06
RCH II
62
FMR for IV qtr of 2005-06 sent (Y/N)
NRHM
Immunisation'
RCH II
>3
Provisional UCs for 2005-06 submitted (Y/N), due date 30/4/2006
NRHM
Immunisation'
RCH II
>4
Audited statement of accounts for 2005-06 sent (Y/N) (due date
31/7/2006)
NRHM
Immunisation
* ‘tilisation of Funds during 2005-06
RCH II
5
Total amount received from Gol during 2005-06
NRHM
Immunisation
RCH II
6
Unspent Balance as on 31/3/2006
NRHM
Immunisation
Allocated
7
Funds for JSY during 2005-06
Spent
143
Financial status 2006-07
Allocation for year
68
Amount of RCH II envelop (including
JSY.Sterlisation, NSV) during 2006-07
Release till date
Transferred to Districts till date
RCH II
Total funds available with the state (sum of unspent balance of
2005-06 plus amounts received during 2006-07
NRHM
Immunisation
69
RCH II
Expenditure reported during previous quarter of 2006-07
NRHM
Immunisation
70
RCH II
FMR for previous quarter sent (Y/N)
NRHM
Immunisation
71
144
inancial Status - Disease Control Programmes during 2006-07
Allocation for year
Release till date
68
RNTCP
Total available funds with state (including past
balances and current releases
Transferred to Districts during 06-07 till date
Allocation for year
Release till date
58
NVBDCP
Total available funds (including past balances
and current releases )
Transferred to Districts during 06-07 till date
Allocation for year
Release till date
8
NLEP
Total available funds (including past balances
and current releases )
Transferred to Districts during 06-07 till date
145
Allocation for year
Release till date
68
NBCP
Total available funds (including past balances
and current releases)
Transferred to Districts during 06-07 till date
Allocation for year
Release till date
68
NIDDCP
Total available funds (including past balances
and current releases )
Transferred to Districts during 06-07 till date
Allocation for year
Release till date
68
IDSP
Total available funds (including past balances
and current releases)
Transferred to Districts during 06-07 till date
146
Position: 309 (10 views)