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REPORTS OF THE WORKING GROUP ON
HEALTH
FOR
THE ELEVANTH FIVE YEAR PLAN
(2007 - 2012)
XJ
NO-
GOVERNMENT OF INDIA
PLANNING COMMISSION
2006
L-
SI. No. __________________________ Title__________________________
Financial Requirement - proposed outlay for the XI Five Year Plan Period
1
(2007-2012)________
Health Sector Reform Strategy of Madhya Pradesh_____________________
2
Programme Implementation Plan of NRHM__________________________
2
Draft report on recommendation of Task Force on Public Private Partnership
4
for the 11th Plan
5
6
7
8
9
j
Pages
Financial Requirement
Proposed Outlay for the XI Five Year Plan
I
Period (2007-012)
'I-'
I
In Respect of:
1. Scheme : Strengthen of Health Information and
Monitoring Systems
I
2. Telemedicine (Scheme yet to be proposed by Union
I
MOHFW/GOI)
i:
IP
• 1
52
rI?
2.7 External Quality Assurance System :
There is limited availability of institutions who have capacity and/or experience of
conducting EQAS of laboratory services. It was decided to engage NICD, Delhi, NIV,
Pune, NICED, Kolkata and CMC, Vellore to share the responsibility. CMC Vellore was
given the responsibility to work out detailed proposal. This has been submitted and being
examined.
2.8 Monitoring of the Pro ject through Regional Coordinators
‘‘Expression of Interest” was sought for Monitoring of Project through six Regional
Coordinators to be posted at Chandigarh, Bhopal, Bangalore, Gandhinagar, Kolkata and
Guwahati. 22 organisations had expressed interest. Six agencies were short-listed. After
seeking clearance of the World Bank, RFP was issued to the six agencies. Proposals
have been received on 21st March 2006 and evaluation of the proposals has been initiated.
Report would be submitted by April 2006.
2.9 Participation of Private Sector and Medical Colleges in IDSP
A Workshop was organized in April 2005 in Bangalore to discuss strategies for
involvement of private sector. A task force was constituted to develop scheme for
involvement of private sector in disease surveillance. A scheme including MOU was
prepared and forwarded to Indian Medical Association and Indian Academy of Pediatrics,
who have agreed to facilitate participation in IDSP. Four Orientation Workshops of key
members of these associations were planned of which two have been organized in Delhi
and at Thiruvanthapuram. Third workshop is being organized in Mumbai on 16th April
2006. Scheme for participation of medical colleges has been prepared and forwarded to
the States and other stakeholders.
I
I
I
2.10 NCD Risk Factor Surveillance
The Working Group was constituted for development of protocol for NCD Risk factor
Surveillance. After several meetings, Study design and Sampling has been worked out.
Questionnaire to be used during the surveys has been finalized and being pre-tested.
Terms of reference for National Nodal Agency, Regional and State level Institutions have
been forwarded to the World Bank for clearance. Surveys would be undertaken after
awarding the contract.
I
I
I
2.11 Satellite Communication :
EDUSAT, a dedicated educational satellite launched by ISRO is being utilized to set up
communication and information network throughout the country. Central studio at
National Institute of Communicable Diseases with a sub-hub in Nirman Bhawan and 800
Satellite Interactive Terminals (SITs) located throughout the country would be set up
connecting all the State and Districts Units, Medical Colleges and premier state and
national public health institutions. Proposal has been submitted to the World Bank for
clearance.
This network will be utilized for distance training programmes,
teleconferencing and data transmission. Funds have been sanctioned from EDSP Budget
for 2005-06 to ISRO to cover 400 SITs by June 06. Remaining 400 SITs would be
covered during 2006-07 and covered by December 2006. Satellite Linkage would be
formally launched on 29th March 2006.
60
I
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I
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2.12 Information, Education & Communication
2.12.1 Guidelines, Operations Manuals and Reporting Formats
For an effective surveillance system, case definitions, operational procedures, reporting
formats etc. have been standardized by publishing and disseminating following formats :
• Operations Manual for District Surveillance Units
• Operations Manual for Medical Officers and Private Practitioners
• Operations Manual for Health Workers
• Laboratory Manual on Disease Surveillance
• Training Manual for District Surveillance Teams (Rapid Response Teams)
• Manual on Financial Management
• Standard Reporting Formats and Guidelines for their use
• Guidelines on Utilization of grant-in-aid
• Brochure/Executive Summary on Integrated Diseases Surveillance Project
• National Project Implementation Plan
A manual on Laboratory Techniques has also been developed by National Institute of
Communicable Diseases and would be used in the Project. Separate Manuals for Lab
Technicians posted at PHCs/CHCs and Manual on Bio-safety have been drafted and
would be published and disseminated.
2.12.2. Medical Agency
“Expression of Interest” was sought for selecting Media Agency at the central level. 18
organizations had expressed interest. EOI are being assessed and short-listing would be
completed by 15lh April 2006.
2.12.3. Alternate approaches of communication
A proposal to capture information through alternate means of communication has been
prepared to capture information regarding focal out-breaks in the country through
scanning of newspapers and tele-news and by supporting Toll Free telephone services.
Details are given at Annexure 4.
2.13 PIP from Phase-II States
State PIPs have been received from all Phase-II States/UTs (Haryana, Goa, Gujarat,
Chhattisgarh, Rajasthan, Nagaland, West Bengal, Manipur, Orissa, Tripura, Pondicherry,
Meghalaya, Chandigarh and Delhi). MOU is awaited from Meghalaya. First instalment
of GIA has been released to the states, who have submitted MOUs. Orientation
workshops have been organized by Gujarat, Haryana, Chhattisgarh.
A Workshop was organized in October 2005 to orient Phase-III states about preparation
of State PIP. It is expected to get PIPs from remaining states early during the year 200607.
2.14 Prevention & Control of Avian Influenza
Following the outbreak of Avian Influenza in chickens in Maharashtra and Gujarat, two
meetings were held with the officials from the World Bank. A draft Project
Implementation Plan on Surveillance Prevention and Control of Avian Influenza in India.
61
3. BUDGET ALLOCATED & UTILIZED
Since inception of the Project, Rs.810 million has been allocated for IDSP and additional
Rs. 1020 million is available during 2006-07 as indicated below:
(Rs. in million)
BE
Utilization________
Year
RE
300.00
260.00
2004- 05
250.10___________
550.00
2005-06
880.00
487.30
2006- 07
1020.00
3.1 Component wise utilization :
Funds allocated for the project are utilized under three main Heads
i. Central level activities : these include Training of Trainers, Surveys and Studies,
Monitoring & Review, Consultancy services and Operational expenses by CSU.
ii. Grant-in-aid to States : Funds are released to State Surveillance Units through
identified societies for utilization at the State level and distribution to District
Surveillance Units. These funds are utilized on renovation & furnishing,
procurement of minor equipment and consumables, training of personnel, IEC
activities, personnel cost and operational expenses. A separate Head is meant for
NE States of the country.
iii. Commodity Assistance : Major laboratory, office and IT equipment and some
consumables are procured centrally through ICB/NCB and supplied to consignees
identified by the States.
Funds utilized for the above three components during last two years are summarized
below:
Expenditure
Component__________
11.1_______
Central level activities
227.9
Grant-in-aid to States
Grant-in-aid to NE States
11.1_______
0.00_______
Commodity Assistance
250.1
Total 2004-05________
39.8_______
Central level activities
2005-06
299.7
Grant-in-aid to States
41.5
Grant-in-aid to NE States
106.3
Commodity Assistance
_______ ________________________
487.3 *
Total 2005-06
* Expenditure incurred/committed upto 20th March 2006
Year
2004-05
(Rs. in million)
Percent________
4.4____________
91.2___________
4.4____________
0
8.2
61.2
8.5
21.8
L
3.2 Budget Allocation for 2006-07
Allocation for 2006-07 has been substantially raised to expedite implementation of
the project. Provisional break-up of budget is given below :
Component
Amount
miHion)
Central level Activities
Salaries of Incremental Staff
Domestic Travel Expenses
j Training at Central Level
3.500
2.000
2.500
62
(Rs.
in
)
5
Central Level IEC
5.000
Consultancy : Procurement, Software Development and
Baseline Surveys
130.000
Operational Cost___________
Sub-total (Central Activities)
7.000
150.000
Assistance to States
GIA to State Societies for various State/District Level 400.000
activities
GIA to Societies for North-Eastern States for various 90.000
activities
Commodity Assistance Lab/Office equipment. Computer 380.000
hardware/so ftware
Sub-total Assistance to States
870.000
Total Budget for 2005-06
1020.000
3.3. Disbursement Status:
Claims for reimbursement of expenses have been submitted to CAAA to the extent of
Rs. 13 million covering the period upto September 2005. Application for further
claim of approximately Rs. 11 million is under preparation and will be submitted to
CAAA shortly.
X
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63
Annexure-II
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OB Systeni
If Combined
Report and
Recommendations
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.Government of ln<fia
Central Bureau qf Health Intelligence (CBHI)
General of Health Services
.
------------------------------------------- —------------CBHI email: dircbhi^nb.nic.in
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CBHI Website : www.cbhidghs.nic.in
64
)
Regional Workshops for Improving and
Strengthening Health Information System
J
"J
's
Northern and Western Regions
New Delhi: 28-29 August, 2002
Southern and Central Regions
Bhopal; 8-9 May, 2003
Eastern and North Eastern Regions
Bhubaneswar: 22-23 January, 2004
Follow up Workshop
New Delhi: 7 April, 2004
Combined Report & Recommendations
Compiled and Edited by
Dr. Ashok Kumar, M.D., Director
Smt S Jeyalakshtni, Joint Director (NFSG)
Sh. P K Mukhopadhyay, Joint Director
Central Bureau of Health Intelligence (CBH1)
Directorate General of Health Services
Ministry of Health &: Family Welfare
Nirman Bhawan, New Delhi -110 011
In collaboration with
World Health Organisation
CBHI Website: www.cbhidghs.nic.in
CBHI email: dircbhi@nb.nlcJn
HIS strengthening
65
I
’WtRtai iter
110 OH
GOVERNMENT OF INDIA
DIRECTORATE GENERAL OF HEALTH SERVICES
NIRMAN BHAWAN, NEW DELHL110 011
TEL, NO. 23018438. 23019063
FAX NO. 91-11-3017924
Dr. S.P. AGARWAL
M.S. (Surg.) M.Ch. (Neuro)
DIRECTOR GENERAL
Dated.
30th August, 2004
FOREWORD
The health data originate from the periphery levels and flow upward to District, State
and Centra! levels. The Central Bureau of Health Intelligence (CBHI) is the national
nodal institution for health statistics in the country. Similar nodal division is essential
to be established by each State/UT in their respective Health & Family Welfare
Directorates.
In order to facilitato national updated health database, CBHI regularly collects health
information from the Directorate of Health & Family Welfare Services of States! UTs
and other source agencies. For improving and strengthening health data collection
from the States’ UTs and electronic health data transmission through e-mail (direbhi
nb.nic.ln). CBHI through four regional workshops had closely interacted with all
States/UTs.
i
These workshops deliberated in detail on the issues and constraints influencing the
health information system and through this report have come out with important
recommendations towards its efficient functioning at all the levels of health care
delivery The sincere efforts on parts of all the States/UTs and various concerned
organizations in prompt implementation of these recommendations will go a long
way for achieving our National Health Goals.
(S.P. AGARWAL)
t/IS strengthening
66
EXECUTIVE SUMMARY
!
Central Bureau of Health Intelligence (CBHI) is the national nodal
Institution for Health Statistics in the country. The Directorates of Health Services
of States/UTs are the primary source agencies for health data and responsible for
its transmission to central level. In order to improve and strengthen health data
collection & flow from States/UTs to CBHI, a series of regional workshops were
conducted with the objectives to suggest:
(1) to improve & strengthen the timely flow of validated requisite health information
from StatesAJTs to CBHI as well as to enhance the linkages.
(2) to improve & strengthen the infrastructure, both, physical and functional for
efficient Health Information System from periphery through State/UT.
(3) for computerized Health Information System by the States/UTs and timely health data
dispatch to CBHI through electronics means.
(4) for improving the annual CBHI publication “Health Information of India ”m terms of
need for including new data series, modifying present data series and presentation as well
as requirement for new publication(s) on relevant health related aspects.
(5) for strengthening the use of ICD-10 for morbidity & mortality coding by all
mcdical/health care facilities in the States /UTs, and
(6) enhanced efforts of States /UTs towards optimal utilization of CBHI’s in-service training
programs for better human resource development and capacity building for efficient
health information system.
Four workshops were organized in order to cover all States/UTs viz (i) Northern &
Western Region, 28-29 August 2002 at YMCA New Delhi, (ii) Central and
Southern Region, 8-9 May 2003 at Academy of Administration, Bhopal, (iii)
Eastern and North Eastern Region, 22-23 January 2004 at Bhubaneswar and (iv)
Follow up workshop for all those states/UTs which could not attend earlier
workshops, 7th April 2004 at Dte GHS, Nirman Bhawan, New Delhi.
Each Workshop programme included Registration and Inaugural Session, Plenary
Technical Sessions wherein the problems in data receipt from States/UTs faced by
CBHI, introduction to website of CBHI and presentations by States/UTs about
their health information system & its functioning etc. were made and deliberated.
Subsequently the groups discussions were held towards the workshop objectives and their
reports were thoroughly discussed during the plenary session leading to finalisation of
the recommendations.
Besides the representatives from the States/UTs, these workshops were attended
by senior officers & experts from Dte GHS, Department of Family Welfare, the
Registrar General of India, WHO, National Informatic Centre (Central & State),
Central Statistical Organisation (CSO), Planning Commission, National Health
Programmes, Institute for Research in Medical Statistics (ICMR), Medical Record
Officers of state Hospitals and officers of CBHI.
Twenty one major recommendations as emerged on the six broad objectives of workshop
are
summarized in
the next chapter.
It could
be seen that most of these
recommendations are feasible to be implemented immediately while a few like
establishment of an equipped State /UT & Distt. Health Statistic cells and
computerization of Medical/Health Information system need to be initiated now
so that they can be possibly implemented in due course with appropriate planning
and resource mobilization.
67
Major Recommendations
L
To improve & strengthen the timely flow of validated requisite health
Information from States/UTs to CBHI as well as to enhance the linkages
1.
While prioritizing Efficient Health Information System (HIS), to begin with the
existing State/UT health statistics unit in health directorate be strengthened with
an identified nodal officers, trained personnel and computer so as to effectively
coordinate for validated health data base & capacity building in State/UT &
closely link with CBHI. Subsequently make efforts for establishing a dedicated
State/UT Health Statistics Division, equipped with adequate infrastructure This
Division be responsible for efficient HIS, validated health database of the
State/UT, monitoring & evaluation as well as capacity building, while keeping
close linkages with CBHI and various reporting unit within the State/UT.
(Action : States/UTs)
2.
States/UTs to punctually and regularly send the consolidated and validated
weekly, monthly, annual reports to CBHI on the prescribed formats. Even ‘Nil’
report is required timely.
(Action : States/UTs)
3.
All the Regional Offices for Health & Family Welfare of GOI also need to further
strengthen their supportive and coordinating roles with the State/UT Health
Directorates for facilitating timely submission of validated data by States/UTs to
CBHI as well as their capacity building for efficient health information system.
(Action: ROHFW/GOI and CBHI/DteGHS)
4.
Central & State/UT Governments may bring an act for compulsory registration of all
private Z non govt, medical institutions and practitioners with the State/UT Government
and mandatory for them to furnish medical/heaith reports to appropriate Govt. Health
Facility in their vicinity.
(Action: Centre and States/UTs)
5.
For better linkages, communication & capacity building, CBHI may hold review
meetings and workshops with States/UTs at appropriate intervals. (Action : CBHI)
6.
The existing CBHI formats for sending health information by States/UTs should be
reviewed for their further simplification while Avoiding duplication and redesign
them as per present need, with definition of the key terminologies used. (Action
IL
To improve & strengthen the infrastructure, both physical and functional,
for efficient Health Information System from periphery through State/UT
7.
At district level, Chief Medical & Health Officer is responsible for all health
statistical activities under whom the existing Distt. Health Statistics cell be
strengthened on priority basis and efforts be initiated to equip this cell with a
dedicated trained officer as its incharge and a Group C staff oriented in computer
operation and atleast one computer with accessories. This Distt. Health
Information Unit can then coordinate for efficient health information system in
the district, including on the spot supervision and related capacity building of
PHCs & other Medical/Health units in the district.
(Action: States/UTs)
68
8. An expert group to review and suggest an appropriate Health Information System
(HIS) from subcentre to district to state level with reference to the contents of
records/registers, data recording, their validation, appropriate reporting and analysis
for timely corrective measures at various levels. A manual to this effect needs to be
prepared and shared for better understanding and uniformity of HIS at all levels and
by all concerned authorities/ agencies.
(Action: CBHI and States/UTs)
9. At PHC/CHC/Dispensary level, the medical officers and health supervisors should be
oriented to health data management through continued supportive supervision and
wherever necessary through in service training program organized by State(s)/UT,
CBHI and other Institutions. A close coordination with all the existing govt./non
govt, health institutions in respective jurisdiction will ensure maximum coverage of
health & medical data with requisite quality & timeliness.
(Action: States/UTs)
10. To strengthen Health Information System at Sub-centre/PHC/CHC Level, the
State/UT may ensure the full compliment of Multipurpose H.W. (Male & Female),
Health Supervisor, Doctors and other supportive staff as per GOI norms with their
specified responsibilities and continued supportive supervision
(Action: States/UTs)
11. At the Sub centre level the non-availability of formats/registers needs be taken
seriously and the State/UT may ensure their adequate supply & timely replenishment.
(Action: States/UTs)
[II.
For Computerized Health Information System by the States/UTs and timely
health data dispatch to CBHI through electronics means.
12.
Validated and authenticated health data should be transmitted by States/UTs to
CBHI through electronic media (e-mail: dircbhi@nb.nic.in) with immediate
effect as all the States/UTs have been sensitized to this effect by CBHI during
2003-04 and computerised data entry formats of CBHI are already available in
CBHI website (cbhidghs.nic.in) for this purpose.
(Action: States/UTs)
13.
The data collection for CBHI may be done through computerized formats to be
made available on the Internet. Necessary on-line and off-line systems may be
designed in order to automate this process and NIC’s expertise may be used for
designing appropriate systems including databases. NIC’s connectivity in
districts and states can enable on-line updation as well as transmission of data
electronically.
(Action: CBHI & NIC)
14.
Like CBHI has developed a central website for health information, the States/UTs
may also initiate efforts to develop similar websites along with district specific
health information, while utilizing the available expertise of state & districts NIC
units.
(Action: States/UTs and State/Distt. NIC)
69
15.
States/UTs may initiate steps towards computerizing the Hospital Information
System in a phased manner to begin with state/regional level hospitals. This will
facilitate efficient hospital database on morbidity & mortality based on ICD-10,
essential for District/State/National Statistics on morbidity & mortality.
(Action: States/UTs)
IV.
For improving the annual CBHI publication “Health Information of
India” in context of need for including new data series, modifying present
data series and Presentation as wed as requirement for new publication(s) on
relevant health related aspects.
(Action: CBHI)
16.
The Annual Publication “Health Information of India (HH)” with latest/updated
information be brought out within six months of the following calendar year and
for this purpose all the States/UTs and other reporting units should furnish
requisite updated information to CBHI positively within three months following
the calendar year. The presentation of HH may be improved in context of welldesigned cover/back pages, quality of inner pages, their printing and contents with
relevant analysis wherever necessary.
Following new health data series are suggested to be included in CBHI
publication “HIT*:
17.
(0
CO
(iii)
(iv)
18.
Morbidity and Mortality due to trauma/road traffic accidents, disaster/natural
calamities.
Incidence/prevalence as well as estimation of important non-communicable
diseases such as diabetes and hypertension, based on sample survey through
NSSO &/or other such agencies.
Data on age, sex & disease specific mortality rates.
State/UT specific innovative schemes for the welfare of people like in
Madhya Pradesh “Rogy Kalyan Samiti, Jan Swasthya Rakshak Samiti and
State Illness Fund”.
CBHI may bring out publication on; (i) Information on hospitals for specialised
treatment including facilities available, cost thereon etc., and (ii) Directory of
Health Research Organisations, including National Surveys in health and related
subjects, along with brief on their contributions.
For strengthening the use of ICD-10 for morbidity & mortality coding by all
medical/health care facilities in the States /UTs.
ICD-10 coding system be implemented throughout the country for comparison at
19.
both, national and international levels and the use of ICD-10 be concurrently
monitored by hospital administration for timely corrective measures at various
levels, including meeting the ICD-10 trained manpower needs
(Action: States/UTs)
Both, CBHI and States/UTs should design and initiate appropriate training course
20.
on ICD-10 for human resource development/capacity building at all levels,
instead of presently run long (5 weeks) course on Medical Coding. WHO may
support CBHI for training of master trainees on ICD-10 from all States/UTs. Only
trained personnel should be kept for efficiently handling the medical & health
records.
(Action: CBHI, States/UTs and WHO)
70
V.
VI.
Enhanced efforts of States /UTs towards optional utilization of CBHI ‘InService Training programs for better human resource development and
capacity building for efficient Health Information System.
21.
States/UTs may ensue all measures to fully utilize the in-service training
programs of CBHI on Health Statistics and Medical Coding (ICO-10) as well as
Medical Record Management, being organized for various categories of
medical/non-medical staff involved in handling medical/health data, for which
purpose CBHI communicates its annual training calendar well in advance to all
States/UTs. For this purpose, every State/UT should prepare district wise
inventory of such training needs, people trained and remaining to be trained and
utilize this inventory for promptly recommending the names of untrained
personnel to various CBHI in-service training courses.
(Action: States/UTs and other agencies requiring training of their staff)
****4c]fc**]|c*****
71
Annexure - III
Government of India
Improving and Strengthening the use of ICO
10 and Medical Record System in India
A Case Study (2004 & 2005)
Report and Recommendations
LI
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-
*
■
Central Bureau of Health Intelligence (CBHI)
Directorate General of Health Services
Ministiy of Health & Family Welfare,
Nirman Bhavan, New Delhi - 110011
CBHI email: djrcbhi@nb,nic.;u
CBHI website: www.cbhidghs.nic.in
72
Mild tUchR
IMil
fWui
Dr. R.K. SRIVASTAVA
M.S. (Ortho) D.N.B.(PMR)
DIRECTOR GENERAL
on
GOVERNMENT OF INDIA
DIRECTORATE’GENERAL OF HEALTH SERVICES
NIRMAN BHAVAN, NEW DELHI-110 011
TEL. NO.: 91-11-23061438, 23061063
FAX NO. : 91-11-23061924
E-mail; dghs@nic.in
rakeshsrivastava789@hotmall.com
FOREWORD
The International Statistical Classification of Diseases and Related Health Problems 10th.
version (ICD 10) Is the International standard prescribed by World Health Organisation. Countries need
to adopt and Implement this classification so that the morbidity & mortality databases are comparable
withih the various region/states of the country and between countries of regfon/worid. Such reliable
bfomnation are essential for meaningful conclusion on the health status of the population and for
planning the devefopment of facilities for medical and health care and their efficient functioning. ICD 10
coding was introduced by WHO in the year 1993 and India adopted the same in the year 2000. India is
to move alongwith the other countries of world. CBHI’s continuing efforts to promote use of ICD 10 will
yield results only if all the medical & health authorities decide to implement ICD 10 and work towards it.
A case study on ICD 10 involving 20 Delhi & Rohtak hospitals belonging to various
management categories, as undertaken by Central Bureau of Health Intelligence (CBHI) with the WHO
Biennium 2004-2005 support is an appropriate effort in this direction. This case study involved the
Medical Record Officers, heads of Medical Record Departments, Medical Superintendents of the
hospitals and other administrative authorities. These officials and authorities who were oriented on the
importance of implementing ICD 10, committed to provide the requisite support and logistics to the
Medical Record Departments for efficient use of ICD 10 coding system. Through workshops, review
meetings and visits to the medical establishments during this case study; the issues and constraints
influencing the use of ICD 10 were identified and deliberated in detail on their feasible solutions. This
study has come out with valuable recommendations for improved use of ICD 10 as well as
strengthening the Medical Record Departments in the country.
Implementation of ICO 10 system necessitates continued sincere efforts in the form of
orientation training programmes and computerized Medical Record System Departments in all medical
& health institution. From 2005 onwards, CBH! has taken the important initiatives of conducting short
term national level Orientation Training Courses on ICD10. CBHI has also devebped a Module and
Workbook for Orientation Training on ICD 10 which serves as a handy self learning material for all
concerned medical, nursing & paramedical personnels.
I hope that all the concerned medical & health authorities of various states/UTs as well as
medical/health institutions will make every effort to efficiently imptement the recommendations of this
case study.
(Dr. R.K.Srivastava)
EXECUTIVE SUMMARY
Hospital records coded uniformly using ICD 10 form a vast data base and
conclusions drawn on the processed data are extremely important for understanding the
public health situation of the country. World Health Organisation (WHO) brought out the
10th version of International Statistical Classification of Diseases and Related Health
Problems (ICD 10) in 1993 for systematic coding of morbidity and mortality causes in
the medical records of medical/health institutions. India adopted this classification in the
year 2000. Five years have gone by since the adoption of
ICD 10 in India and
evaluation of the implementation and use of ICD 10 by the Medical and Health
Institutions needed to be done, in order to examine the extent of use of ICD 10, various
problems, constraints and bottlenecks experienced and to come out with a model for
improving and strengthening the use of ICD 10 and Medical Record System in the
country and to assess the practical training needs and identify the processes which need to
be initiated / speeded up to gear up the proper use of ICD 10. For this purpose, CBHI
undertook a case study of 20 hospitals in Delhi and Rohtak under the ageis of WHO/GOI
Biennium 2004 and 2005.
This case study of 20 hospitals in cities of Delhi and Rohtak spanning over the
various management categories such as Central Government, State Government, Local
Bodies and Private Sector consisted of the following well thought of initiatives :
Workshop of key trainers on ICD 10 from cities of Delhi and Rohtak (New
Delhi: 21-23 July 2004)
2.
First Review Meeting of key trainers on the action plan and efforts made to
improve and strengthen the use of ICD 10 and identification of the major constraints
and techno logistic
requirements (New Delhi: 03 September 2004)
3.
Visit of experts to the study hospitals for on the spot assessment on the status as
well as
techno-operational and administrative constraints in the use of ICD 10
(11-14 October 2004)
Second Review meeting of Key Trainers on ICD 10 and the Incharges of Medical
4.
Record Department to review the implementation of the action plan for improving
the
use of ICD 10 and strengthening the medical record system (New Delhi:
17 November 2004)
Review Workshop of key trainers on the major actions undertaken in order to
5.
improve the regular use of ICD 10 as well as to strengthen the MRD in the
hospital (New Delhi:
25 January 2005)
1.
The workshop of key trainers on ICD 10 was conducted during 21-23 July
2004 at conference room of YMCA New Delhi. In this workshop. Medical Record
Officers/Officials of 20 study hospitals from Delhi and Rohtak (Post Graduate
Institute) participated. These hospitals belong to various management categories such as
Centre, State, Local Bodies and Private Institutions. During this workshop, the
participants were introduced to - ICD 10 rules for morbidity and mortality coding and
experiences of ICD 10 use in South East Asia Region. Through group work and self
work sessions, the measures for improving and strengthening the use of ICD 10 in each
hospital were discussed and the participants drafted the hospital specific action plan,
logistics and support requirements for efficient use of ICD 10. Resource persons were
73
drawn from World Health Organisation Country Office, South East Asian Regional
Office of World Health Organisation (SEARO), Ministry of Statistics and Programme
Implementation, All India Institute of Medical Sciences, Office of Registrar General of
India (RGI), Maulana Azad Medical College (MAMC) and State Bureau of Health
Intelligence (SBHI), New Delhi.
I
The follow up first review meeting of all those representatives from 20 study
hospitals who participated in the July 2004 workshop, was held on 3rd Sept. 2004 at
Resource Centre, Dte.GHS/GOI, Nirman Bhawan, New Delhi wherein the participants
made presentations on the efforts made towards the use of ICD 10 and/or its further
improvement in the Hospitals, major problems and constraints experienced ( with feasible
solutions) to operationalise and/or improving use of ICD 10 and further support and
logistics required from Hospital Administration and CBHI for ensuring better use of ICD
10 in the hospitals. During the afternoon session, the participants were taken to
Indraprastha Apollo Hospital, New Delhi for demonstration of computerized system of
coding and maintaining medical records. The ICD 10 (3 volumes) were provided to all
those hospitals which did not have the same in their Medical Record Departments
(MRD). Also, a self work in three groups on “Action plan, logistics and support
requirements for efficient use of ICD 10 in their hospital and suggestion in workbook on
ICD 10 training were done. Experts and resource persons were from MAMC and office
ofRGL
Subsequently the 6 hospitals of the case study where no coding system of
Medical Records was being used were visited by CBHI officers during 11-14 October
2004 for on the spot assessment and discussions with hospital authorities and MRD
officials. The very purpose of this visit was to recognise the constraints and problems
which were preventing the Medical Record Department of the hospitals from effectively
using ICD 10 coding in the Medical Records/System. Also, the current status on the use
of ICD 10 and their further plans on its implementation were discussed. Suggestions
were given by visiting CBHI officer to the Medical Record Department officials for
effective use of ICD 10 in the hospital.
The 2nd review meeting on implementation of ICD 10 of these 20 hospitals was
held on 17th November 2004 (1000-1800 hrs) in Conference Room of NIHFW, New
Delhi. During this 2nd review meeting, the medical officer/authority incharge of
Medical Record Deptt. from 20 study hospitals were also invited alongwith the
Medical Record Officials who participated in the earlier workshop and review meeting.
The efforts made by the hospital authorities for implementing ICD 10 and action taken to
handle major problems and constraints and further support and logistics required from
hospital authorities and CBHI for ensuring continued use of ICD 10 were discussed,
which was followed by self work session in which each hospital identified specific issues
requiring further attention for coding the morbidity and mortality records according to
ICD 10 and prepared hospital specific action plan to address these issues. The “ICD 10 (3
volumes)” on CD-ROM were provided to all the Govt, hospitals for facilitating the use of
ICD 10.
As already planned, in the final stage of this case study on ICD 10 , review and
concretization of the actions undertaken by the hospitals was done in order to come out
with a model to improve and strengthen the use of ICD 10 in the country. The review
74
t
workshop was organized on 25th January 2005 (0930-1730 hrs) at India Habitat Centre,
New Delhi, wherein the (i) hospital authorities viz. Medical Superintendents and
Medical Officer Incharges of Medical Record Departments of the 20 study hospitals
from Delhi and Rohtak, (ii) administrative authorities of Govt under which these
hospitals function viz. DHS of NCT of Delhi, Medical Officer of Health from MCD and
NDMC, (iii) Director Medical and Health Services of Railways and ESI, (iv) Director
CGHS/Dte.GHS, as well as (v) experts from WHO and various partners i.e. RGI,
Ministry of Statistics and Programme Implementation, Medical College(s), concerned
authorities for MOHFW and Dte.GHS/GOI, deliberated and made far reaching
recommendations for improved use of ICD 10 in future.
The Proceedings of the individual workshops and review meetings are attached as
Annexure I, II, HI, IV and V respectively. The copies of Technical Presentations are also
annexed. Major recommendations as emerged during the deliberations of the different
activities of the case study are summarized in the next few pages. The implementation
of these recommendations will definitely result in improved use of ICD 10 in the
medical/health institutions across the country.
*********************
75
MAJOR RECOMMENDATIONS
A.
Essential use of ICD 10
1. All Government and Private health and medical institutions in the country should
essentially use ICD 10 in their records and reports and the same should be ensured
by all concerned authorities through well designed guidelines, directives and
continued monitoring.
[Action : Centre and States/UTs]
2. All medical and health institutions, including hospitals of any size, in the country
should equip themselves with WHO publication on ICD 10 (3 volumes) as a
reference and ICD 10 codes relevant to each medical specialty be prominently
made available in concerned wards in the hospitals. No medical record should
remain without ICD 10 code for the diagnosed disease.
[Action : Centre, States/UTs and Respective Medical and Health Authorities]
3. CBHI should be appropriately further strengthened and equipped to efficiently
function as National Nodal Institute on ICD 10 with the objective of further
strengthening use of ICD 10, its continuous monitoring, evaluation and capacity
building including creation of Master Trainers.
(Action : CBHI ]
4. WHO may consider setting up of WHO Collaborating Centre on Family of
International Classification of Diseases and Related Health Problems for SE Asia
Region, on priority basis, at CBHI, Dte. General of Health Services, Govt, of
India, New Delhi
[Action : WHO and CBHI ]
B.
Manpower Capacity Building for ICD 10 Use
5. All State/UT authorities should formulate a plan for regular orientation training
on the use of ICD 10 and every medical and health institution should make efforts
to keep their medical/nursing/paramedical staff duly oriented on ICD 10 through
well drawn and regularly conducted Orientation Programs in their institutions.
[Action : States/UTs and Respective Medical & Health Authorities]
6. The syllabi and curricula of undergraduate and postgraduate medical as well as
paramedical courses in India should appropriately cover the teaching on ICD 10
and its appropriate use.
[Action : All concerned Councils]
C.
Operational Plan for implementation of ICD 10, its Monitoring
and Evaluation
7. States/UTs should set up a task force for time-bound implementation and
monitoring of ICD 10 use. They should maintain a database of various medical
and health institutions using/not using ICD 10 and ensure that all these institutions
use ICD 10.
[Action : States/UTs]
76
8. WHO may develop offline software package for ICD 10 coding of disease
nomenclatures and provide it for its use in various medical/health institutions in
India. Computerised user manual/self learning module for ICD 10 may be
prepared and circulated through website of CBHI. Further, online help and a
newsletter on ICD 10 aspects may be established through CBHI website. CBHI
should make an inventory of all such vendors which are involved in designing the
health information system using ICD 10 and share the list with States/UTs for
getting the institution specific hospital information system designed through a
suitable agency.
[Action : CBHI and WHO]
9. Directives need to be issued from heads of the medical/health institutions to all
concerned Medical/Nursing/Paramedical personnel of all departments in the
medical/health institutions for ensuring completion of medical records of both
outpatient and inpatient departments, and for clearly writing diagnosis using
standard medical terminology, while avoiding the abbreviations.
[Action : States/UTs and Respective Medical and Health Authorities]
10. Data on morbidity/mortality based on Medical Records should be regularly
compiled, analysed and should form the part of various documents/reports of the
medical/health institutions including their annual report.
[Action : States/UTs & Respective Medical and Health Authorities]
11. There should be regular visits / interaction by CBHI to facilitate the speedy
implementation of ICD 10 in the States/UTs.
[Action : CBHI & States/UTs ]
D.
.
j
Strengthening Medical Record Unit/Department
Computerised Medical Record System
and
12. The medical record system in each medical/health institution should be
computerized with appropriately designed software for both outpatient and
inpatient records, while using meticulously designed formats, local area network •
as well as internet facility in all the departments/wards of the medical/health
institution.
[Action : States/UTs and Respective Medical and Health Authorities]
13. The medical record department in each medical/health institution should be given
highest priority and be headed by a senior level expert/officer of the same rank as
in other existing technical departments in the same institution. The medical
record department should be equipped with requisite number of trained personnel
of different categories like medical record officer, Dy. Medical Record Officer,
Assistant Medical Record Officer, Sr. Medical Record Technician, Medical
Record Technician and other support staff in order to efficiently handle and
manage the medical record system of the institution. The standardized staffing
pattern of medical record department, keeping in view the bed stieiigth in an
institution be worked out by the concerned State/UT authorities and medical
record departments in various medical and health institutions be equipped
accordingly.
[Action : States/UTs and Respective Medical and Health Authorities]
77
14. All the technical functionaries in the medical record department be trained
through the prescribed training programmes and such training personnel should
not be diverted to other departments. The contribution of medical record
department functionaries in any of the research papers be duly acknowledged.
(Action : States/UTs and Respective Medical and Health Authorities]
J
15. There should be clear guidelines for period of retention of medical records for
both outpatient and inpatient departments and after the said period, they must be
destroyed. This will provide adequate space for the records.
[Action : States/UTs and Respective Medical & Health Authorities ]
*************************
'si
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78
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Policy Reform '
Health Sector
Options Database (HS-PROD)
Govt, of India
Min. of Health & FW
Dte. General of
Health Services
"Sharing innovative solutions to common health management problems"
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Central Bureau
of Health
Inleiligence
(CBHI)
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HS-PROD is a user friendly, state-of-the-art website which shares information about Indian good practice
and innovations in health services management. An instantly accessible library of reform materials, it
provides a summary of each option/schcme and links to more details source documents. The aim is to
share reform know how to tackle common management problems in the health sector. HS-PROD
currently contains carefully researched entries, in respect of 16 major Health Sector Areas as given below
and the database is expanding rapidly:
(10) Access to service and coverage
(1) Infrastructure and equipment
(11) Health Financing
(2) Logistics
(12) Human Resources
(3) Financial management systems
(13) Community Participation
(4) Monitoring, evaluation and quality control
(14) Urban Health
(5) Public/private partnership
(15) Behavioral Change Communication
(6) Management structures and systems
(16) First Referral Units
(7) Social marketing and franchising
(17) Others
(8) Health information systems
(9) Intersectoral links
I
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■.
Developed as a collaborative initiative between the Government of India (GOI) and the EuropeanUnion,
HS-PROD now resides with the Central Bureau of Health Intelligence (CBHI), Directorate General of
Health Services in the Union Ministry of Health & Family Welfare and is being further developed with
technical support from the National Institute of Medical Statistics, Indian Council for Medical Research,
New Delhi.
HS-PROD is managed by the CBHI through a broad-based management group with representatives from
Government development partners, NGO/Private Sector and experts from the fields of Public Health,
Economics, Bio Statistics, IT etc. The group meets every quarter but approves each new entry added to the
database concurrently.
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Many States face similar problems in the health sector but have no way of sharing their experiences or
ideas with each other. They may have heard of successful schemes in other parts of the country but do not
know how to get more detailed information about them.
The internet is an excellent way of promoting Indian reforms, and especially partnerships with the private
sector and NGOs, both within India and worldwide.
It is an efficient and low cost means of sustaining and replicating reforms instigated by GOI, development
partners and other organizations.
It has valuable potential as a learning resource for health sector reform training events and courses
(HS-PROD already forms part of the professional development course in Public Health, Management and
Health Sector Reform)
It fits well with thcrevised role of the Ministry of Health & Family Welfare in a more decentralized context.
It encourages and supports convergence between sectors.
It represents an ideal tool for communicating good practices under the National Rural Health Mission
(NRHM) and Reproductive and Child Health (RCH2) Programme.
It meets a need for information that is continually expressed. Feedback at State level has been extremely
positive. During field visits, the HS-PROD team has been repeatedly told that this is a tool that people
want and need
I
Each HS-PROD entry is described in terms of concise summary, location, duration, advantages,
challenges, prerequisites for implementation elsewhere (such as consultation); implementer etc. The aim
is to provide up-to-date and accurate information about options or interventions, using a standard format
and to organize such options systematically.
Sahiya movement (community health workers), Jharkhand : more than 1000 sahiyas providing quality
health care services to the needy in marginalized sections of the community, particularly women and
children in remote, unreachable areas.
Corporate policy on HTV/AIDS, Larsen & Turbo, Powai, Maharashtra: orientation on HIV/AIDS
awareness to over 10,000 employees, 4500 family members and 1600 local children.
Primary health care and RCH services in urban slums, Uttar Pradesh : A public-private partnership
I
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www.hsprodindia.nic.in
www. p rod - i nd ia. corn
providing primary health care and reproductive and child health services in eight identified slums pf
Varanasi City.
■
Providing round-the-clock comprehensive emergency obstetric and new bom care centers, Tamil Nad;-\ ,
leading to a drop in maternal mortality rate by 36 percent between 2001 and 2005.
Provision of essential maternal and child health services in Tribal Areas, Rajasthan in each village a tribfA
woman working as a health volunteers or Swasthya Sakhis who carry out community based education &
distribution and accompany women & children to health centers.
i What kind of source documents can I access through HS-PROD ?
Each entry provides a basic summary of 'good practice' or innovation plus the ability to access a range Or
source material for those interested in more detail. The material includes Government Ordejrx
powerpoint presentations, evaluation reports, photographs, video clips, newspaper articles and links to'
relevant websites. Where the source item is too big for immediate access through a hyperlink, a requ^X
can be e-mailed directly to the HS-PROD team at CBHI. The HS-PROD reference library is already ~a
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valuable and extensive resource freely available to all users.
HS-PROD Users & Beneficiaries
;
HS-PROD users include Central/State/UT/ District health and other related authorities including NRH1W
(Central /State),Govemmental/Non governmental organisations in health and related fields, including
Research, Education & Training, Regional offices of MOHFW & CBHI, ICMR Institutes, CBHI FiexJ
Survey Units to undertake visits for collecting on the spot information on HS-PROD, ECTA state
facilitators. Developmental partners (WHO, EC, UNICEF, WB, USAID, etc.). Media, internet aiO
Individuals
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LHowJoiaccessl^^
At www.prod-india.com or you can request the CD from CBHI. This website is being shortly movedO
www.hsprodindia.nic.in.
How dalfiiid what l am Ipo^g for j^ H^ROD ?
HS-PROD entries are listed by the subject areas (16) as explained above. There is also a search facili^J
which allows you to search by keywords or by HS-PROD reference number. Facility for searching entries
by States has also been incorporated.
Yes. You can enter your information online through the website (help screens are available) or by sending' I
a Word document by email to dircbhi@nb.nic.in. The HS-PROD team will then contact you to verify tl|-s j
entry.
I
The database itself focuses exclusively on the huge number of excellent initiatives in India but details of
related international experience are also included.
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Yes. HS-PROD has a module devoted to links with other national and international websites. The team
seeks to maximize such connections while maintaining the focus on India in the database to avoi£) i
duplication of content.
No, the emphasis is rather on management and organizational matters in health.
I
The HS-PROD team carries out regular field visits to States/UTs to meet various health authorities O |
national health programme manager and learn about initiatives at first hand. In addition, they hear aboiik !
reforms through the media, the Internet and the regional offices of the CBHI, NIMS and EU. They th^N
contact those involved in the project for more information. However the HS-PROD team does not carp\
out an independent evaluation of each reform. It demands proof of results (such as evaluation reports) bur
it is up to the HS-PROD user to make their own judgment as to whether the reform is useful or not.
Howoftenaretheentriesupdated?
... • \
The HS-PROD team aims to update each entry as and when required. However each option is dated so tK /
user can see when the information was last revised.
JKPfTAL
What are ihe plans for HS-PRODm thc future ? 7
While HS-PROD has been developed as an operational information tool, it also has great potential asQ*
learning resource for training events and courses in health sector reform and capacity development. This
learning aspect of HS-PROD will form a major part of the on-going development programmes under tl(")
National Rural Health Mission (NRHM). In addition, a discussion group facility is being developed so
that users can discuss projects online. The number of entries increases every month and region^)
workshops have been organized in order to sensitize & encourage the use of the website and to generate
new entries.
:
F
A Few Examples of HS-PROD entries
i Devolution of financial and administrative powers to districts,
i riaryana-(35)
Haryana State Government has sought to improve the efficiency of
management at various levels of the health service through greater
decentralisation, in keeping with national policy.
State
Government Orders were issued to devolve powers according to
rank. Medical Superintendents, for example, are now able to buy
drugs and equipments upto the value of INR 50,000 per purchase,
while Senior Medical Officers can spend INR 10,000 and Medical
Officers INR5,000.
0
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Mitanin programme, Chattisgarh (49)
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A ''Mitanin" is a Community Health Volunteer (CHV) trained and
deployed under a State-wide programme in Chattisgarh, where
levels of disease are high and use of health services low. The
mitanin is a married local women whose main role is to organize
and empower women, provide health education, facilitate access to
health care and provide referral advice. A State Health Resource
Centre, set up under a Memorandum of Understanding between
the State Government and Action Aid India, was formed to guide
the programme which effectively extends outreach of all existing
projects.
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Public Private Partnership for delivering of reproductive and
! child health services to the slum population of Guwahati city.
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Urban health services in Guwahati have improved since the State
Government contracted a trust hospital (Marwari Maternity
Hospital) to provide services in eight low-income wards of the dty.
In addition to State funds, vaccines and contraceptives are
provided free of charge to the hospital which now covers 17
outreach sites in slum areas providing Reproductive and Child
Health services. Sterlisation, spacing and termination services are
free to patients; deliveries, operations and diagnostic tests are
charged at concessionary rates.
I
Operationalisation of First Referral Units, Maharashtra (103)
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In 2002 Washi rural hospital was upgraded to First Referral Unit and
provided with a dedicated EMOC team consisting of three
specialists; a gynaecologist, an anaesthetist and a paediatrician
besides other staff.
Facilities at FRU Washi, include an operating theatre, blood
transfusions, laboratory services, x-ray facilities, ambulance
services and medico-legal works including post-mortems. As a
result between 2000-2005 obstetric admissions have risen from 562
in 2000 to 971 in 2004; deliveries have more than doubled from 328
to 700; livebirths have risen from 325 to 685; obstetric complications
treated have gone from nil to 164 and there have been no maternal
deaths at the hospital since July 2002.
afe drinking water in the villages of Rajasthan (124)
o
9
0
Availability of safe drinking water is a pre-requisite for good health. To
tackle the water shortage in the districts of Churu, Hanumangarh and
Jhunjhunu of Rajasthan, the Aapni Yojana scheme was designed to
supply drinking water from Indira Gandhi Canal to 1000 villages and 11
towns at an affordable price. Funding for the project was provided by
the Government of India (GOI) and the German government, through
its development bank, Kreditanstalt fuer Wiederaufbau (KfW). By
March 2006, the project had expanded to 370 villages and two towns,
covering, 20,000 square kilometers and 900,000 people. It is benefiting
mainly those engaged in agriculture and animal rearing. The overall
objective was to improve the health status of the population.
I
A Few Examples of HS-PROD entries
Promoting change in reproductive behaviour of youth, Bihar (178’
)R<ra
Change in reproductive behaviour of adolescents and youth ip.
Bihar is being promoted by PRACHAR Project of Pathfind6~3
International through the support of 30 Non Governmental
Organisations. The program is widely accepted in the 552 villages J
where it was implemented. The project has reached more thap
90,000 adolescents and young adults with information on key issued
in Reproductive Health and Family Planning. More than 100,000
parents and other community adults received similar messaged
aimed at building wide social acceptance for the ideas of delayin’
and spacing children.
L
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The HamaraProject, Rajasthan (177)
The Hamara Project is a replicable programme model for HIV
prevention and care for migrant men and their sexual partners from
two sates-Rajasthan and Karnataka. India Canada Collaborative
HIV/AIDS Project (ICHAP) with collaboration from Rajasthan State
Aids Control Society is running the programme and Candian
International Development Agency (CIDA) is providing assistance
to the program. The project has covered 30,000 Migrants, 24,000
migrants' wives and 6,000 "potential" migrants.
E
(
r
Traditional healers provide health care in tribal
pocket, Chattisgarh (168)
O
A suitable strategy was evolved by the distric^-x
Collector and Chief Medical Health Officer (CMHO),
Bastar whereby traditional healers known as SirheCj)
Gunia-Baigas were made partners in promotion of
modern health care services among the trib^ )
population. Currently, Bastar district has 1500 Sirha;
Gunias-Baigas as depot holders. This initiative hac. /
helped service providers in their work. According tp».
the CMHO of Dantewada, the initiative has led ter'
fewer causalities and deaths in the district.
. i
0
For more details, please contact: Dy. Director General & Director
Central Bureau of Health Intelligence
Directorate General of Health Services,
Nirman Bhawan, New Delhi-110011
Tel/Fax : 91-11-23063175 and 23062695
E-mail : dircbhi@nb.nic.in
CBHI Website: www.cbhidghs.nic.in
HS PROD Website : www.hsprodindia.nic.in(www.prod-india.com)
■i
i
This information is:
• Of a general nature only and is not intended to address the specific ( \
I
Bum'
Medicine bag provided to Milanins
r
October 2006
circumstances of any particular individual or entity;
• Not necessarily comprehensive, complete, accurate or up to date;
I/
• Sometimes linked to external sites over which the CBHI has no
control and for which it assumes no responsibility;
|
• Not a legal advice and if you need specific advice, you should )
always consult suitably qualified Professionals.
J
I
i
Annexure - V
Concept Paper
On
Telemedicine in India
Submitted to
First Meeting of
National Task Force on Telemedicine
OH
IO01 October, 2005
Ministry of Health, Govt, of India, New Delhi
83
Background Paper in Telemedicine in India
1. Introduction:
With its huge area of 32,87,268 Sq km, population of 1.4 billion, urban-rural
divide, inaccessible hilly regions, islands and many tribal areas, India is an ideal setting
for telemedicine assisted health care delivery. Growing number of medical, paramedical
colleges and schools with lack of adequate infrastructure, learning materials and teachers
needs is a matter of grave concern. E health technology has the potential to create a
national level GRID which can form the backbone to be shared by healthcare providers,
trainers and beneficiaries.
A strong fiber backbone and indigenous satellite
communication technology in place with large mass of human potential trained in IT and
local presence of telepathy industry, e health application and implementation should not
be a problem technically. Further a number of pilot projects over last five years with
successful outcome stand to its testimony. Groundwork on telemedicine in the country
has already been laid with the efforts of ISRO and Information Technology department
partnering with many State Government and specialty Institutes/hospitals. Policy
standardization and infrastructural issues have already been researched. Professional
societies on telemedicine/e health have been active. Print and electronic media are
participating in awareness campaign.
However, a country level plan is long due to steer the Telepathy ship by the
Captain (M/o Health & Family Welfare/GOI) with its crew (technology and healthcare
providers/educators) and passengers (citizen) in right direction (policy, implementation,
application, security, social and legal issues) to reach at the destination (Quality
healthcare & wellness).
As has been happening globally, the technical agencies like ITU, NASA have
taken a lead in the technical issues and the health agencies like WHO had been watching
these technical developments closely over the years and now has taken over the mandate
under its own arena as “strategy 2004-2007 e-health *or Health-care Delivery”
(www.who.int/eht/ehealthHCD/), the Ministry of Health, Govt of India has been
watching the development in the country and is now following the same strategy as a
member state of WHO.
We have collated data on telemedicine/ e health obtained from different sources
and tried to summaries in the following presentation.
84
2. Telemedicine in India- Current Scenario
2.1.1 Initiatives taken by different Govt/Publie sector & Private Agencies
Different govemment/public sector/ and private agencies are venturing into Tale
healthcare by providing hardware and software solution for tele-health care. Efforts are
directed towards setting up ‘standards’ and IT enabled healthcare infrastructure in the
country. Some of those activities are summarized below:
Indian Space research Organization (ISRO) Initiatives
ISRO telemedicine pilot project was started in the year 2001 as a part of proof-of-concept
demonstration programme. Telemedicine system consists of customized medical software
integrated with computer hardware along with medical diagnostic instruments connected
to the commercial VS AT at each location. The medical record/history of the patient is
sent to specialist doctors, who study and provide diagnosis and treatment during
videoconference with patient’s end.
During the year, telemedicine network has been further expanded and it now covers 100
hospitals- 78 remote/rural/district hospitals/ health centre connected to 22 super specialty
hospitals located in the major cities as follows:
•
Nine hospitals in Jammu and Kashmir, six district hospitals including Leh and
Kargil and three medical college hospitals connected to All Indian Institute of Medical
Sciences, Delhi, Apollo Hospitals, Delhi and Amrita Institute of Medical Sciences,
Kochi.
•
Five islands ok Lakshdweep (Kavaratti, Amini,- Agatti, Andrott and Minicoy)
connected to Amritha Institute of Medical Sciences, Kochi.
•
Five remote /field/base hospital of Indian Army connected to research and refferal
(R&R) Hospital at New Delhi. INHS, Dharvantri under the naval Command at Port Blair,
Andmans connected to R&R Hospital, New Delhi.
•
Eleven hospitals of North Eastern States (STNM Hospital Gangtok, Sikkim
regional Institute of Medical Sciences, Imphal, Manipur Medical College Hospital,
Guwahati and District Hospital at Udaipur, Tripura) connected to Asia Heart Foundation,
Kolkata.
•
Tata Memorial Cancer Centre, Mumbai connected to B B barua Cancer Centre,
Guwahati and Wai Waker Rural Cancer Centre at Chiplun, Maharashtra.
•
Three Medical College Hospital of Orissa connected To SGPGI, Lucknow.
•
Operational telemedicine network in Karnataka -11 district / taluk hospitals
connected to five super speciality hospitals in Bangalore and Mysore.
Besides the above, a temporary telemedicine facility was set up for two months at Pamba
at the foothills of Sabrimala shrine for, the benefits of visiting pilgrims. A mobile
teleopthalmology facility has been provided to Shankara Netryalaya, Chennai and
Arvinda Eye Hospitals, Madurai to extend services to rural population of Tamilnadu.
Operational telemedicine network is being established at Chhatisgarh connecting 14
district hospitals/health centers to Raipur Medical College Hospitals.
85
More than 25000 patients have so far been provided with teleconsultation and treatment.
An impact study conducted on thousand patients has revealed that there is a significant
cost saving in the system since the patients has revealed that there is a significant cost at
the hospitals in the cities.The Andman Telemedicine Network consisting of telemedicine
Centres at G B Pant Hospital, Port Blair, Bishop Richardson Hospital, Car Nicobar and
INKS, Dhanvanthri Naval Hospital at Port Blair alongwith the Andmans Gramsat
Network was extensivelyused for tele-consultation and tratment in the aftermath of the
tsunami that hit the island.
Source: http:/ww.isro.org/rep2005/SpaceApplications.htm accessed on 23rd Sept 2005.
2.1.2 Department of Information Technology (DIT), Initaitives
M/o Information and Communication & Technology, Government of India:
Department of Information Technology (DIT), as a facilitator, has taken initiatives for
development of technology, initiation of pilot schemes and standardization of
Telemedicine in country. The pilot schemes take into account the diverse issues related to
currently available telecommunication infrastructure, specialist availability, geographical
considerations, etc. Some of these initiatives are:
DEVELOPMENT OF TELEMEDICINE
As a part of promotion of Telemedicine in India, Department of Information Technology
has supported development of technology at different premier institutions in India. The
major consideration to develop a Telemedicine platform included its cost effectiveness
and conformity to standards so that interoperability between different systems could be a
possibility. Efforts have been made to ensure that these systems are compatible with
most of the available communication infrastructure in India like PSTN, ISDN, Leased
lines and V-SAT. During the development, clinical specialist from major institution like
SGPGIMS, Lucknow, PGIMER Chandigarh, AHMS, New Delhi were also associated to
benchmark the technology for its user friendliness and acceptance. A number of
Telemedicine software systems including Mercury & Sanjivani by CDAC and Telemedik
by IIT Kharagpur have been developed and are in use.
TELEMEDICINE PILOT SCHEMES
Some of the pilot projects initiated by Department of Information Technology are
presented below:
■
Tele-medicine for diagnosis & Monitoring of tropical diseases in West Bengal
using low speed WAN, developed by Webel (Kolkata), IIT, Kharagpur has been
installed in School of Tropical Medicine Kolkata and two district hospitals. More
than a thousand consultations have already taken place over this network.
Another two projects on setting up of telemedicine facilities at five referral
hospitals and nine district hospitals using the above technology are also under
implementation. Part of this network is already under effective utilization. The
system uses the high speed leased lines and West Bengal State Wide Area
Network (WBS WAN) as the communication backbone.
86
■
The above technology is also being employed to set up a telemedicine network in
the state of Tripura where two referral hospitals in the capital Agartala are being
connected with four sub-divisional hospitals. Govinda Ballav Panth Hospital at
Agartala has already been connected with the 4 Nodal hospitals and more than
175 consultations have taken place since the inauguration of the network in June
2005.
■
An Oncology Network for providing Telemedicine services in cancer detection,
treatment, pain relief, patient follow-up and continuity of care in peripheral
hospitals (nodal centers) of Regional Cancer Centre (RCC) has been established.
The project is implemented by C-DAC, Trivandrum and RCC. More than 4000
patient consultations have been done till date using the network. . A cost benefit
analysis has shown major economic benefits to the patients. The project is now
being upgraded to include high bandwidth VS AT connectivity and other advanced
features in Tele-consultation.
In another project Telemedicine & Telehealth Education facilities are being set up
of in Kerala using the Technology developed by CD AC Pune in which three
speciality medical hospitals are being linked up with 4 District/Rural Hospitals.
Continuing Medical Education (CME) will also be part of this project.
■
Another pilot scheme of setting up telemedicine centers has been undertaken
connecting Apollo Hospital, Delhi with district hospitals in the states of Mizoram
and Sikkim with technology developed by CD AC. District hospital at Namchi in
south Sikkim and Civil Hospital, Aizwal, in Mizoram have been connected with
Apollo Hospital and regular consultations have started.
■
Department of IT earlier facilitated setting up Telemedicine system at Naga
Hospital, Kohima that is connected with Indraprastha Apollo Hospital, New
Delhi. The project was commissioned in partnership with M/s. Marubeni India
Private Limited with financial assistance from Govt, of Japan. The network is
effectively used for continuing medical education of the doctors and paramedical
staff of Naga Hospital.
■
A Telemedicine network connecting 14 remote hospitals with Indira Gandhi
Medical College Shimla is being set in Himachal Pradesh to provide quality
healthcare consultations to population in those areas. Fibre Optic communication
backbone of the state is being utilized in this project. CD AC is providing the
technology and implementing the project.
STANDARDIZATION ACTIVITY IN TELEMEDICINE
To streamline establishment of telemedicine centers and standardize services available
from different Telemedicine centers need to define a set of standards and guidelines for
practice of telemedicine is felt. The document, “Recommended Guidelines & Standards for
Practice of Telemedicine in India”, has been prepared by Department of IT through deliberations
of Technical Working Group and is aimed at enhancing interoperability among the various
Telemedicine systems being set up in the country. In addition to suggesting standards for various
equipment needed for setting up Telemedicine centers, it also provides guidelines for
conducting Telemedicine interactions.
87
BUILDING FRAMEWORK FOR IT INFRASTRUCTURE FOR HEALTH (ITIH)
An exercise has been carried out to suggest a framework for ITIH to efficiently address
all information needs of different stakeholders (government, hospitals, insurance
companies, patients, vendors and others) in the healthcare industry. The framework
addresses to the key elements of Standards, Legal framework and Medical Informatics
Education. ITIH framework prescribes appropriate standards for each stakeholder across
diverse healthcare settings towards build an Integrated Healthcare Information
Infrastructure for India. A document titled “The Framework for Information Technology
Infrastructure for Health in India” has been prepared and is being widely disseminated
through DIT website for feedback and comments from the different stakeholders and
public infrastructure for Health in India.
2.1.3. State Govt initiatives in partnership
Jammu & Kashmir
The Telemedicine Pilot Project in Jammu & Kashmir, undertaken by ISRO is extended to
cover district hospitals of Kargil, Kupwara, Poonch, and Doda. These hospitals will soon
have telemedicine connectivity with the Shere-Kashmir Institute of Medical Sciences,
Srinagar, the Government Medical College, Srinagar and the Government Medical
college, Jammu. Further, they will also have connectivity with super speciality hospitals
in Delhi and Kochi.
Source: http://janimukashmir.nic.in/gov/SNL aprilmay.pdf
Himachal Pradesh (Under Implementation)
To provide specialized medical care and treatment to the patients in the remote and
inaccessible areas from the speciality hospital, the community and primary health centers
of Himachal Pradesh will be connected to General Hospitals and IGMC Shimla which in
turn will be connected to PGIMER, Chandigarh, a super speciality hospital, by CDAC
under DIT, Govt, of India. Twenty four locations have been identified for the
deployment of the project - 14 centres are to be taken in the Phase I and rest of the
centers would be connected in the Phase H.
Uttaranchal Telemedicine Project
In April 2004, Uttaranchal Government started this project with the support of Online
Telemedicine. Research Institute, Ahmedabad to provide speciality consultation and
distance learning to the doctors of the district hospitals of Uttaranchal region. In the first
phase two district hospitals of Srinagar and Almore got connected to SGPGIMS,
Lucknow, a tertiary level referral hospital
Punjab Telemedicine Project
Aimed to provide modem health facilities at affordable prices in remote areas, Punjab
Government in April 2005 launched a Telemedicine project linking PGIMER,
Chandigarh with three hospitals i.e Mata Kaushalya Hospital at Patiala, the sub-divisional
government hospitals at Dasuya and Ajnala in Hoshiarpur and Amritsar districts
respectively.
Source : http://www.hindu.com/2005/04/14/stories/2005041405310500.htm
88
West Bengal Telemedicine Projects
A “Non Profitable” project sponsored by Rabindranath Tagore International Institute of
Cardiac Sciences (RTIICS), Kolkata, Narayana Hrudayalaya (NH) Bangalore, Hewlett
Packard, Indian Space Research Organisation (ISRO) and state Governments of the seven
North Eastern states of India. The Rabindranath Institute at Kolkata and Narayana
Hrudayalaya at Bangalore will be the main hub for Telemedicine linking the seven states.
Orissa Telemedicine Project
This project is sponsored by Indian Space Research Organisation and Govt, of Orissa, in
2003, to support the distant medical education programme. Three Medical colleges of
Orissa i.e. SCB Medical College, Cuttack, MKCG Medical College, Behrampur and VSS
Medical College, Burla are connected to SGPGIMS via VS AT at 384 kbps bandwidth.
Maharashtra Telemedicine Project
The Pune district administration in partnership with global health portal and Tata Council
for Community Initiatives has launched a telemedicine service to connect all the primary
health centers in the district for speciality consultation. In the first phase, three PHCs in
Wagholi, Chakan & Paud regions would be linked with the district administration and
specialist
Source : http://www.itforchange.net/resources/20 initiatives.html
Karnataka telemedicine Network Project
In the first phase of Karnataka telemedicine project Narayana Hrudayalaya at Bangalore
linked to Distrit Hospital, Chamarajanagar in Mysore district and Vivekananda Memorial
Hospital, Saragur and in the second phase of this project smaller hospitals in all the 25
districts in North Kanara and the Western Ghats, including NGO and trust hospitals will
link with the super speciality hospital Narayana Hrudayalaya and Rabindranath Tagore
International Institute of Cardiac Sciences, Kolkata.
Source: http://www.expresshealthcaremgmt.com/20030228/tech2.shtml
Kerala Telemedicine Project
In August 2004 with collaboration of ISRO and C-DAC, Kerala Government launched a
telemedicine project to provide Telemedicine facilities in five medical colleges, 14
district hospitals and two taluk hospitals in Kerala. These hospitals would be in tum
linked with AHMS, New Delhi, AIMS, Kochi, and Sri Chithira Tirunal Institute of
Medical Science and Technology, Thiruvananthapuram. Currently the project is getting
expanded and getting integrated with Kerala Onconet (Cancer Network) with the support
of ISRO and Department of FT, GOI.
Source: http://www/cdacindia.com/html/press/3q04/spot434.asp
In August 2004 with collaboration of ISRO and C-DAC, Kerala Government launched a
telemedicine project to provide Telemedicine facilities in five medical colleges, 14
district hospitals and two taluk hospitals in Kerala. These hospitals would be in tum
linked with AIIMS, New Delhi, AIMS, Kochi, and Sri Chithira Tirunal Institute of
Medical Science and Technology, Thiruvananthapuram.
Source: http://www.cdacindia.com/html/press/3q04/spot434.asp
Regional Cancer Centre, Thiruvananthapuram with the support of department of
information technology had launched telemedicine project called ONCONET to
broadbase diagnostic evaluation and consultation. services for cancer patients with
telemedicine nodes in six points in the state.
89
Andaman & Nicobar Telemedicine Project
This project links the G.B. Pant Hospital in Port Blair with the Sri Ramachandra Medical
College and Research Institute in Chennai.
In ISRO Telemedicine Network, GB Pant Hospital and INS Dhanvantari Hospital two
Hospitals at Port Blair and Indira Gandhi Hospital at Car Nicobar enable the local
Doctors to communicate with speciality hospitals like Apollo Hospital at Chennai and
Amrita Institute of Medical Sciences at Kochi.
Source: http://www.and.nic.in/telemedicine.htm
Lakshadweep
Indira Gandhi Hospital, Kavaratti linked with AIMS, Kochi with the support of ISRO.
Source: http://www.and.nic.in/telemedicine.htm
2.1.4. Super speciality hospital Telemedicine Network (Public & Corporate Sector)
Apollo Telemedicine Network Foundation (ATNF)
Apollo has set up over 45 Telemedicine Centres across different locations in the country
and abroad.
Source : http ://www.who india.org/EIP/GATS/13-Annex2.pdf
Apollo hospital groups project at Aragonda, serves 24 villages covering 48000 people in
the vicinity and provides access to super-specialists at the Apollo hospitals in Chennai
and Hyderabad. The project will soon extend across five states, covering 10 districts and
20 village groups in each state. In the next phase of the project 125 primary,
Maharashtra, Gujarat, Madhya Pradesh, Tamil Nadu and Andhra Pradesh will be
covered. Phase three will connect 500 primary, 500 secondary and 100 tertiary centers
all over the country.
Source : http://medind.nic.in/maa/t05/il/maat05ilp5l.pdf
The Indian Army has tied up with ATNF for setting up of Telemedicine centers to
connect its smaller hospitals in the periphery to its main Command hospitals. Command
Hospital (CH, CC), Lucknow is now the hub center and linked to the military hospitals at
Jabalpur, Allahabad, Namkum, Meerut, Dehradun and Barelly. Apollo Hospitals Group
free Telemedicine consultation at Naga Hospital, Kohima, Guwahati and Tinsukhia in the
North East region.
Source: http://www.telemedicineindia.com/news.html accessed on 23rd Sept. 2005
Telemedicine Initiatives at Sanjay Gandhi Postgraduate Institute of Medical Sciences
(SGPGIMS), Lucknow, Uttar Pradesh
SGPGIMS is linked with three medical colleges of Orissa i.e. Cuttack, Berhampur and
Burla under ISRO/DIT funding and with district hospitals of Almora and Srinagar in
Uttaranchal region under Govt, of Uttaranchal support to provide tele-education, tele
consultation and tele-followup services. Through National Informatics Centre (NIC)
project, CME sessions are conducted monthly towards professional carrier development
of doctors with 8 district hospitals and 450 Community Information Centres of North
East States. SGPGIMS is connected via satellite and ISDN to similar facilities with other
tertiary level hospitals like AHMS, New Delhi, PGI, Chandigarh, AIMS, Kochi,
SRMC, Chennai. Under a project of Ministry of Information Technology, the Mercury
90
and Sanjeevani software for telemedicine was developed by SGPGIMS, ARMS and
PGIMER in collaboration with Centre for Development of Advanced Computing (CD AC) as part of Research and Development. SGPGIMS is now setting up a School of
Telemedicine & e Health in its campus with the objective of meeting the demand of
-highly skilled health technologist in this emerging area. The department of radiotherapy
of SGPGIMS with support of Department of Science and Technology is planning to link
the radiotherapy department of medical colleges of Uttar Pradesh.
Source: www.sgpRitelemedicine.in
The Amrita Institute of Medical Sciences (AIMS) Telemedicine facility
AIMS is presently connected to the following Telemedicine centers in India: SRMC,
Chennai; Sankara Netralaya, Chennai; Indira Gandhi District Hospital, Kavaratti,
Lakshadweep Islands; GB Pant Hospital, Port Blair, Andaman & Nicobar Islands; Sanjay
Gandhi Post Graduate Institute of Medical Sciences, Lucknow; SNM hospital, LehLadakh; Katuah district Hospital, J&K; Govt. District hospital, J&K; Swami
Vivekananda memorial Hospital, Sargur, Karnataka; District Hospital, Camicobar,
Andaman & Nicobar Islands; ARMS, New Delhi; Trivandrum Medical College;
Pattanamthitta District Hospital, Kerala; Narayana Hrudayalaya, Bangalore;
Ravindranath, Kolkata; Ramchandra Bhanja, Cuttack.
The Indian Space Research Organisation (ISRO) has drawn up ambitious plans to extend
AIMS Telemedicine facility to connect 80 more district hospitals to speciality hospitals in
the north eastern states of India.
Source : http://www.chennaionline.com/health/homearticles/2003/AIMS.asp accessed on
23 rd Sept. 2005.
Asia Heart Foundation (AHF)
AHF is an organization working towards establishing cardiac network in and around the
country with establishment in Bangladesh and The Republic of Yemen. Installed in 2002
by Narayana Hrudayalaya, Bangalore, Karnataka it has now achieved a figure of more
than 2000 tele-cardiology consultation through an enterprise based network. Creating a
Hub and Spoke Network between the Tertiary Care Centres in the Cities and the
peripheral Coronary Care units in the remote areas.
Source: http://www.expresshealthcaremgmt.com/2001123l/bangalore2.shtml
Escort Heart Institute & Research Centre Project:
Installed in 2002 by Escort Heart Institute & Research Centre, it has been involved in
telecardiology service.
Mobile Tele-Ophthalmology service:
With the support of ISRO, Shankar Nethralaya at Chennai, Meenakshi Eye mission at
Madurai & Arvinda Eyecare Centre has Centres at Madurai, Theni, Tirunelveli &
Coimbatore districts of South India have launched Mobile Tele-ophthalmology to give
tertiary care service on wheels.
91
Telepathology India
Telepathology India is a free consultancy service and distance learning by the use of the
internet in the field of diagnostic pathology. Telepathology is basically “Second
Opinion” on gross and microscopic images which have been amply proved in the world
literature to be useful for those pathologists staying in remote areas.
Source: http://www.telepathologY.org.in/about.html
3. The Telemedicine/ e Health Grid
The Primary Health Care Centre (PHC) is the first echelon in the health care delivery
system in India, which cater to a group of villages and are posted with General Duty
Medical Officers. There are sub centers under the PHCs, which cater to the remote
villages. Community Health Centers (CHC) are located at the block levels. .
The PHCs and CHCs can.be connected to the respective District/General Hospitals,
where basic speciality care is available. This is as per the existing patient referral chain.
The doctors from the PHCs will be able to take expert opinion from the specialists
without sending the patient. Even if the patient requires specialized treatment at the
CHCs/District hospitals, a prior appointment can be taken, saving the patient a repeat trip
due to non availability of a specialist/malfunctioning equipments.
The District Hospitals can be connected to the regional Super Speciality Hospitals/
teaching hospitals as per the chain of patient referral. The district hospitals can also be
connected amongst themselves, which will help to obtain a second opinion or getting
expert comment from concerned specialists in case of non-availability.
Ultimately a patient can be referred to the national facility centers/premier institutes if so
desired. Due to the vast geographical area of our country and huge numbers of health
care centres, it may not be feasible to keep the whole network under one platform. There
can be independent state level TM networks connected with the countrywide network.
In addition to the above, other govemmental/semi-govemmental organizations like the
railways, defence services, oil and steel PSUs have their own large medical setups. Some
of these organizations have started developing their own TM networks. It may be
planned from the very outset to integrate these smaller networks to the national TM
setup.
i
The issues to be considered for the National Telemedicine/Health Grid (Configuration,
management, layering etc.), will include issues on Telecommunication for e-Health
(defining optimum cost-effective bandwidth application wise, mix and match
connectivity solution etc.), unlicensed spectrum under USO, Co-ordination with
DOT/TRAI/ERNET/Public-Private broadband connectivity providers (BSNL, MTNL,
GAILTel, PowerTel, RailTel, Tatalndicom, Reliance etc.). Wireless LAN option with
WiMax technology. Broadband Internet based telemedicine applications.
4. Implementation issues in Telemedicine
With the rapid growth of telecommunication technologies and the availability of adequate
bandwidth at reasonable cost, telemedicine is bound to spread all over the country and
reach the far-flung areas.
92
A need has therefore arisen to put in place a regulated network with proper referral
mechanism for teleconsultations from the periphery to the super-speciality hospitals. A
basic model for setting up a Telemedicine network with a large teaching hospital at the
apex is proposed in the following paragraphs.
There are certain points which need to be kept in mind before setting up a network for
Telemedicine.
(a) Interoperability : The Telemedicine networks must be able to interface together and
create an open environment which permits the sharing of various applications on different
participating systems in real-time or seamless interface between several applications.
(b) Scalability : It must be possible for the systems inducted to be augmented with
additional features and functions as modular add-on options.
(c) Portability : It must be possible to port data generated on one system to another
platform with minimum effort
(d) Reliability : Telemedicine systems must ensure availability of service with minimum
system downtime.
4.1. Implementation Strategies
In a large country like India having vast area with different environmental and health care
issues, it is important to cany pilot projects for testing and framing/pLanning of any
project at a large scale and extend it country wide. The benefit of the telemedicine must
first be extended at the rural level in plains and difficult terrain and inaccessible areas in
the mountains like Leh and Zanaskar. Careful strategy and planning would ensure that
the bottlenecks that may come in the way of implementation of Telemedicine project are
recognized and removed before it is implemented at national level.
A schematic diagram of a possible referral model is given below which ensures the
availability of the telemedicine facility to be available at the Primary Health Centre
/
•Primary Telemedicine Centre (PHC/CHC)
Secondary Telemedicine Centre (District Hospital)
Tertiary Telemedicine Centre - LI (State Medical College/Regional Super-speciality
medical Centre)
.
Tertiary Telemedicine Centre -L2 (Apex Hospital like AHMS)
It is therefore necessary to prepare such pilot projects in different parts of the country to
work simultaneously, results of which may help establish the national grid in a successful
manner.
93
Annexure
i ■
Table-1 State wise location of telemedicjne platforms
Types of
District hospital, CHC & PHC
State
SL
Communi
No.
cation
_ VSAT
Jammu & Kashmir Kargil, Kupwara, Poonch, Doda? Leh
1
Chamba,
Tissa,
Hamirpur,
Dhramshala,
RecongLeased
Himachal Pradesh
2
Peco,
Kullu,
Sangla,
Mandi,
Shimla,
Rampur,
line,
Implementation)
Khaneri, Rohm, Pooh, Nichar, Bharmaur, Bilaspur, VSAT &
Keylong, Nahan, Solan, Una, Killar, Shalai, Kwar, ISDN
Udaipur, Kaza ___________________
Mata Kaushalaya Hospital, Patiala, Govt
VSAT
Punjab
3
Hospital, Hoshiarpur & Amritsar
Almora & Srinagar Base Hospitals
ISDN
Uttranchal
4
Funding and
Implementing
Agencies
ISRO________
DIT, CDAC
ISRO
Govt
of
Uttranchal
& ITT Kharagpur,
Webel
ECS
Ltd.
ISRO, DIT
5
West Bengal
Coochbehar, Habra, Midnapore, Behrampur,
Suri, Purulia
ISDN
VSAT
6
Orissa
VSAT
7
Maharashtra
Medical Colleges at Cuttack, Burla, and
Berhampur
Primary Healthcare Centres Wagholi, Chakan &
Paud villages of Pune
8
Karnataka
VSAT,
ISDN
9
Kerala
Mandya,
Maddur,
Tumkur,
Shimoga,
Chitradurga,
Bagalkot,
Yaddgir,
Gadag,
Kawar(operational), Bidar, Gulbarga, Bijapur,
Raichur, Belgaum, Dharwad, Coppala, Haveri,
Bellary,
Davangere,
Udipi,
Chikmangalur,
mangalore, Hassan, Madikeri, Mysore, Kolar,
Sirsi(to be linked)._____ ________ ________ _
14 district hospital and 2 taluk hospital, Kollam,
Kozhencherry, Kochi, Palakkad and Kannur
10
Andman & Nicobar G B Pant Hospital and INS Dhanvantri Hospital
in Port Blair, Indira Gandhi Hospial at Car
Nicobar are linked with Sri Ramachandra
Medical College and Apollo Hospital, Chennai.
Lakshdweep
Indira Gandhi Hospital, Kavaratti linked with
AIMS, Kochi.
_______
VSAT
DIT,
ISRO,
CDAC,
Trivandurm,
Malabar
Cancer Society
ISRO
VSAT
ISRO
11
VSAT,
ISDN
Table II. Super Speciality Hospital Telemedicine Network (Public & Corporate Sector)
94
Pune District
Adm, Global
Health portal
& Tata Council
for Community
Initiatives
ISRO
■ V
St
No
Speciality Telemedicine nodes linked with
Super
Hospital
1.
SGPGIMS
Lucknow
2.
3.
4.
5.
> ?
6.
7.
8.
Orissa, Uttaranchal State network
ARMS, New Delhi
PGIMER Chandigarh_______________________
AIMS, Kochi, SRMC, Chennai_______________
Eight states of North East____________________
All India Institute of J&K network, Haryana (Rohtak Medical College,
Community Centre),
Cuttack,
Medical
Sciences, Ballabgarh
New Delhi_________ Guwahati, Chennai, Kochi___________________
Punjab and Himachal network, SGPGIMS
PGIMER
Lucknow, ARMS, New Delhi
Chandigarh
ISDN
VSAT&ISDN
VSAT
ISDN, VSAT
VSAT, ISDN
Funding
Implementing
Agencies_____ ,
ISRO,
DIlJ
Govt, of Oriss
Uttaranchal
DIT,
CDAC
Mohali
NIC_________
DIT, ISRO, Cs
DAC, Mohali
ISRO, DIT anr/
Govt, of Punjal
and Himachal
ISRO
Institute SRMC, Chennai; Sankara Netralaya, Chennai; VSAT
Amrita
Sciences Indira Gandhi District Hospital, Kavaratti,
Medical
Lakshadweep Islands; Andaman & Nicobar
(AIMS), Kochi
Network; Sanjay Gandhi Post Graduate Institute
of Medical Sciences, Lucknow; J&K Network;
Swami Vivekananda memorial Hospital, Sargur,
Karnataka; ARMS, New Delhi; Trivandrum
Medical College; Pattanamthitta District Hospital,
Kerala; Narayana Hrudayalaya, Bangalore;
Ravindranath, Kolkata; Ramchandra Bhanja,
Cuttack, AIMS Emergency Medical Centre,
Pampa
______________________________
Cancer
Hospital
at Barshi, Dr. B. Barooah Cancer
Tata
Memorial
Institute
at
Guwahati,
Dr. Walawalkar Hospital at
Hospital, Mumbai
Dervan, Chiplun, Six Hospitals in the North east
and Regional Cancer Centres_________________
ISRO
Heart Rabindranath Tagore International Institute of VSAT
Asia
Cardiac
Sciences
(RTIICS)
Calcutta,
Narayana
Foundation,
Hrudayalaya (NH), Bangalore
Bangalore
ISRO
VSAT
Shankar Nethralaya, Mobile tele-ophthalmology
Chennai, Meenakshi
Mission
&
Eye
Eyecare
Arvinda
Madurai
Centre,
(Mobile
Teleophthalmology)
Apollo
Hospital Apollo Hospitals, Hyderabad, Aragonda 33 nodes in ISRO,
Apollo
Telemedicine
India
village in Andhra Pradesh
Group
Network
24 villages
Foundation
(ATNF)
*************
95
!
Type
of
communicatio
n___________
VSAT, ISDN
Flag C
Annex 1
Madhya Pradesh
Health Sector Reform Strategy (HSRS)
(2006-12)
1.0
Introduction
MP is one of the poorer states of the country with more than 37% of its
population (22 million) living below poverty line. SCs and STs
constituting 35% of the population, account for the majority of the poor.
State has low sex ratio (920 as compared to 933 for the country) and
low female literacy (50% as compared to 54% for the country). Health
status is characterised by high maternal and child mortality (MMR of
498 as compared to 409 for the country, I MR of 79 as compared to 64
for the country), high fertility (TFR of 3.3 as compared to 2.9 for the
country), high burden of vector borne and communicable diseases and
weak public health system with extremely low per capita public
expenditure (Rs 132 as compared to Rs 207 for the country).
State has taken many steps in the recent past to improve the
functioning of the health system and facilities. These efforts have
acquired a new focus and thrust with the launch of the National Rural
Health Mission that has become the umbrella programme for all vertical
disease control programmes, including RCH. State has already signed
MOU with the GOI committing itself to increasing public expenditure on
health, increased decentralization and community participation,
provision of community level health worker (ASHA) and granting
functional autonomy to local health facilities. State has also prepared a
Programme Implementation Plan (PIP) for NRHM and RCH covering
the period up to 2012. These PIPs outline the operational plans of the
government to reform the health systems for providing equitable and
quality health care to its people.
This document outlines the current status of health system and its
performance and strategy and the programme for reforming it. The
strategy is largely based on the government policy and programme as
contained in NRHM and RCH PIPs (Annex 1 and 2 respectively), which
might be referred to for details. Recognising that all actions contained
in the comprehensive reform programme may not be implemented at
the same time, an Early Action Plan (EAR) has also been prepared to
focus on the urgent reform priorities.
One of the challenges for the state will be to arrange adequate funding
for the reform programme and to build capacity for implementing it.
State has committed itself to an annual 10% increase in public
expenditure on health. These would be supplanted by GOI support for
various programmes. However, it is anticipated that these sources may
not be adequate for implementing the programme. Government will, on
priority, finalize a Medium Term Expenditure plan for implementing the
reform programme to assess gaps in fund availability and seek external
assistance for bridging it.
2
2.0
Current Status of Health Outcomes and Health Systems
in Madhya Pradesh1
State has made significant progress in reduction in MMR, IMR and
CMR over the last 7 years. However, these are still worse than national
averages and quite poor as compared to better performing states.
Inequities in access and health outcomes extremely low expenditure on
health and that too largely as out of pocket and high incidence of
communicable diseases like TB and Malaria characterise the health
status of the status. The current status of health outcomes and working
of the public and private health care systems are discussed below.
2.1
Status of Health Outcomes
The salient health indicators are detailed in the following table:
1.
2.
3.
4.
5.
6.
7.
8.
9.
MMR (SRS 1998)
IMR
Under 5 mortality
rate
TFR
Women receiving 3
Antenatal Check ups
% of children fully
immunized
Institutional
Deliveries
%
of
child
malnourished
Unmet need for FP
Kerala
(NFHS 3)
UP
(NFHS 3)
88
142
All India
(NFHS 2)
407
68_____
95
15
73
3.1
40%
3.4
27%
2.9
20%
1.9
94%
3.8
26%
40%
22%
42%
75%
23%
30%
22%
33%
100%
22%
60%
54%
50%
29%
47%
12%
17%
16%
9%
22%
MP
(NFHS 3)
498
70
MP
(NFHS2)
Based on the above, and the details contained in NRHM PIP (Annex
1), the major highlights of the health outcomes and key intermediate
indicators are:
•
•
•
High MMR and IMR with significant rural-urban, socio-economic
group wise and inter-district variation both in health outcomes and
utilisation of health services.
High level of malnutrition amongst children and anaemia amongst
women.
High Gender disparity - CMR for girl child is 87.5 as compared to
49.2 for boys.
1 This section is primarily based on NFHS 2 and 3 data, NRHM and RCH PIP, Draft Report of
the Group on Health Financing for the Xlth plan and data contained in the Situation Analysis
done by HLSP for GoMP in 2002. Although, some of the data might be dated, the broad
conclusions still hold good.
3
•
•
•
•
•
•
2.2
IMR is double and CMR is more than five times in poor families as
compared to well off families. Similarly, 12% of children in poor
families were vaccinated as compared to 50% of well off.
Only 11% OF ST children were fully immunized as compared to
22.4% for the state as a whole.
Poor awareness of ORS therapy, while 28% of the state’s IMR was
due to diarrhoea.
MP contributes 24% of malaria cases, 40% of PF cases and 20% of
malaria deaths in the country.
Poor coverage of sanitation facilities in rural areas.
Increasing prevalence of TB with poor detection as well as cure
rates in majority of districts.
Status of Social determinants of health
Madhya Pradesh is one of the India’s poorer states, with a per capita
income in 2003-04 of Rs. 8,284 compared to the all-lndia average of
Rs. 11,799. More than 37% of its population live in poverty. For
Scheduled Tribes (20% of the population) and Scheduled Castes
(15%), the poverty levels are higher, at 57% and 40% respectively.
Gender inequalities are reflected in the low sex ratio (920/1,000,
against a national average of 933), female literacy of 50% and lower
Human Development Indices for women. Within the state, there are
significant regional inequalities, with extremely high poverty levels in
southern and south-western districts compared to northern districts.
High levels of poverty and gender inequalities impact on key social
determinants of health:
• 53% of women are married before the legal age of marriage (18
years) with this indicator as high as 72% for women with no
education.
• 13.6% of the women in the age group of 15-19 years were either
pregnant or were mothers.
• IMR (125) of youngest mothers was twice that of mothers aged 3035(64).
• Prevalence of high anaemia (57.6%) and nutritional deficiency (40%
women have BMI <18) amongst women in reproductive age.
• 70% of ST women are anaemic.
• More than 60% children are malnourished; 40% are stunted and
33% are wasted.
• Only 15% of children were breastfed within one hour of birth and
only 21% of children (0-5 months) were exclusively breastfed.
• 86% of habitations are covered by safe drinking water sources.
However, inadequate arrangements for preventive maintenance of
hand pumps contribute to poor availability of safe drinking water.
• Rural sanitation is still a concern as less than 8% of all rural
households are estimated to have an IHL. This situation is likely to
improve with implementation of ‘Swajal Dhara’ scheme. However,
4
attitudinal awareness and constraints due to non-availability of
water for flushing need to be tackled.
2.3
Inequalities in Health Services Utilisation and Outcomes
There is large variation in utilisation of health services and health
outcomes across regions, between rural and urban population and
across socio-economic groups:
• IMR in urban areas is 47 against 76 in rural areas. While 69%
children in urban areas were fully immunized, only 32% in rural
areas were covered.
• While 66% births in urban areas were assisted by doctor/health
personnel, only 28% births in rural areas were so assisted;
Institutional births in urban areas were 60% as compared to 20% in
rural areas.
• IMR is double and CMR is more than five times in poor families
having a low standard of living index as compared to well off
families.
• 12% of children in poor families were vaccinated compared to 50%
of children of better off families; vaccination coverage in Vindhya
region was 10% compared to 32% in Malwa.
• Tribal areas had significantly worse health indicators (discussed in
detail, later).
2.4
Public Health Care System
The public health care system is characterised by poor coverage, and
indifferent quality of services due to lack of staff, poor resource
availability and low accountability.
• The coverage of public health system is poor. There is a shortage
of 1658 SHCs, 450 PHCs and 120 CHCs. This shortage is based
on population norms and actual access is even poorer if regard is
had to the distance that people have to cover to reach SHCs and
PHCs in remote tribal areas.
• There is a shortage of buildings, equipment, drugs and most
importantly staff, especially medical officers and specialists, in the
existing facilities resulting in unreliable services with people
preferring to go to private practitioners for even minor ailments. As
a result government facilities are often under utilized.
• At the sub-centre level ANM is overloaded with field as well as staff
duties and is unable to provide desirable level of service.
• Poor referral system in operation. People often bypass primary and
secondary level facilities and go directly to tertiary facilities leading
to overburdening of the system and result in inefficiencies.
• Over centralization, poor delegation and financial systems that lead
to inflexibility in working of schemes and delays in utilization of
funds.
5
•
•
2.5
Panchayati Raj Institutions and community have little say in
planning and management of health services. This coupled with
poor internal control systems leads to low accountability.
BCC and IEC plans that are not tailored to local needs and
situation. Less emphasis on counselling and preventive measures.
Institutional framework - Organisation, Management and Systems
The institutional framework of public health system is characterised by
high centralization, poor delegations, weak accountability mechanisms,
weak HR policies, and inadequate control over the private sector.
• GOI plays a key role in laying down the policy and strategic
framework, state allocates funds and manages human resources
and districts and sub-district units are primarily responsible for
service delivery, with very little say in determining the scope and
nature of services. These levels have, therefore, little incentive to
plan for local needs, although this is changing with the recent
initiatives on district health planning.
• The management capacity at district and block level is weak. This,
combined with staff shortages (14% for medical officers, 32% for
specialists and 18% for ANMs), absenteeism, poor monitoring and
poor quality of infrastructure results in poor quality of services.
• Although, interdependence of health outcomes, literacy and women
empowerment, nutrition and water- sanitation issues is well
recognised, holistic management (planning, implementation and
monitoring) does not take place. The resources of various
departments at district and sub-district level are not joined-up for
optimising results.
• Involvement of community in planning and monitoring of health
services is limited and linkages with CBOs and NGOs active in the
health sector are weak.
• Although, RKS have provided some autonomy to the hospitals but
their working needs to improve.
• The HR function at the state level is poorly organised. Cadre
management rules are not linked to policies regarding postings and
transfers. Ad-hoc transfers lead to inequitable allocation of already
scare human resources with staff not willing to join or continue in
poor / inaccessible areas.
• Absence of well structured incentive schemes, unclear guidelines
for career progression and lack of transparency in postings results
in low motivation and morale of the staff.
• Performance appraisal system does not distinguish between good
and bad performance; there is weak link between performance and
career progression.
• Training infrastructure is poorly managed and underutilised. As a
result, a well thought out training and development plan does not
exist.
6
•
Health Management Information system is weak and focused
primarily on measuring activities / inputs. The system overloads
field level functionaries with data collection and provides little
feedback to them leading to insufficient disaggregated analysis of
health service utilization and outcomes.
2.6
Private Health Care Markets
Private sector is the major provider of the health care in the state. In
rural areas, 90% of both minor and major ailments are treated by the
private sector while in urban areas people seek private care for 95% of
the minor and 75% of major ailments2. The private health care market
is characterised by:
• Skewed geographical coverage of private providers with more than
50% of allopath GPs and 75% of the specialists located in urban
areas.
• Presence of large number of unqualified / semi- qualified RMPs in
rural areas, dispensing health care which is expensive and of poor
quality.
• Weak regulation of the private sector. As a result, quality and cost
of care is not checked.
• Poor availability of data regarding private sector which limits the
scope of government to develop suitable partnerships with them for
improving access in poorer regions.
2.7
Financing of Health Care
Health financing in the state is characterised by extremely low public
expenditure, high share of out of pocket expense, poor coverage of
insurance schemes and inefficient targeting of public subsidies.
• Per capita expenditure on health in the state was Rs 1200 as
compared to national average of Rs 1377 (2004-05). Share of
household expenditure is one of the highest (83% as compared to
national average of 73%). Understandably, per capita public
expenditure on health is one of the lowest (Rs 132 as compared to
national average of Rs 207)3.
• Even as public expenditure on health is very low in the state, rich
gain disproportionately more from the curative care as compared to
the poor (the ratio of subsidy of richest to poorest quintile in the
state was 4.16 as compared to the national average of 3.28)4.
These inequalities were more pronounced in rural areas than urban.
The richest 20% of the poor in rural areas enjoy 40% of the
subsidies - the poor 20% only 8.4%. However, targeting is better at
the PHC level and for immunization.
• The share of primary health in total public expenditure on health
has varied between 50-60% recent years which compares
2
Report on the Working of the Private Health Care Market in MP, 2002, TARU Leading Edge.
Draft Report of the Working Group on Health Care Financing for the 11th Plan, GOI, 2006
4
Better Health Systems for India’s poor, 2002, World Bank Publication.
3
7
•
•
•
2.8
favourably with other states. However, more than 80% of the
expenditure is pre-committed for establishment costs (salaries and
wages).
Less than 2% of the population is covered by any risk pooling /
insurance scheme. This, coupled with absence of social protection
scheme, exposes the poor to catastrophic effect of illnesses.
Allocation of public expenditure on health to districts is not done on
the basis of health status or need. This may further accentuate
regional inequalities.
Out of pocket expenditure being the main source of financing of
health care costs; this limits access to care and can have
catastrophic economic and health consequences for the poor.
Health Problems in Tribal regions
MP has a large tribal population, majority of who reside in 8 tribal
districts. These tribal districts are characterised by extreme poverty
(more than 57% tribal population is poor), remoteness, inaccessibility
and extremely weak public health infrastructure. The health outcomes
in these areas are, understandably, extremely poor as compared to
other regions and groups:
• CMR was 87 for ST children as compared to 57 for the state (NFHS
2).
• TFR was 3.9 for SC, 3.7 for ST against 3.3 for the state (NFHS 2).
• More than 70% ST women were anaemic as compared to 54% for
the state (NFHS 2).
• 60% of ST children were anaemic as compared to 51% for the state
(NFHS 2).
• 91% tribal women delivered at home as compared to 78% for the
state as a whole.
Special strategies for improving access and availability of services and
health outcomes in tribal areas will be devised as a part of the health
reform programme.
2.9
Conclusions
Poor and inequitable health outcomes in the state are on account of
poor social determinants of health, constraints on demand as well as
supply side and poor functioning of health markets. Reform of health
sector will require simultaneous addressing of these constraints.
8
3.0
Vision and Objectives of the Health Sector Reform
Programme
3.1
State’s Vision for the Health Sector
State is committed to achieve the MDG targets relating to health and
the targets set under NRHM. The health systems in the state will be
reformed with focus on achieving equitable, affordable and quality
health care for all. The state has, accordingly, adopted the following
vision for the health sector:
‘All people living in the state of Madhya Pradesh will have the
knowledge and skills required to keep themselves healthy, and
have equity in access to effective and affordable health care, as
close to the family as possible, that enhances their quality of life5,
and enables them to lead a healthy productive life’.
The key elements of the vision that will drive the development of health
strategy are:
•
•
•
•
•
Knowledge and Skills: to address social and cultural issues that
impact health seeking behaviour and outcomes, to bring about
changes in behaviour at the individual and community level.
Equity: health infrastructure (both public and private) will be
expanded with a clear focus on the most disadvantaged and
vulnerable districts / groups, poorer regions and groups will be
prioritised for resource allocation, benefits of public services will be
shared equitably.
Effective: to provide services that meet standards of quality, are
effectively targeted at the needs of the poor, are delivered in a cost
effective manner, and health systems that are accountable.
Affordable: public services are affordable to the poor, safety nets
for the poor to cope with the economic and social impacts of serious
illnesses; regulation over quality and cost of services provided by
the private sector.
Healthy Productive life: public health systems will provide a range
of essential health promotion and preventive services, and simple
curative and emergency services and will also promote lifestyle
changes for overall improvement in health of the people of the
state.
5
Quality of life is the perceived physical and mental health of a person or group over
time.
9
3.2
Goals of the Health Sector Reform Programme (HSRP)
The Health Sector Reform programme will be implemented to achieve
the following goals by 2012:
• Reduction in Infant Mortality Rate to 60 per 1000 live births
• Maternal Mortality Rate reduced to less than 220 per 1,00,000 live
births
• Total Fertility Rate is reduced to 2.1.
• Reduction in inequalities (socio-economic, SC and ST, Rural-Urban
and Gender) in health outcomes and utilisation of services6.
• Malnutrition amongst children reduced to 35% from the current level
of 60% and severe malnutrition reduced to <1%.
• Morbidity and mortality due to common communicable diseases
such as malaria, dengue, leprosy, and tuberculosis is reduced as
per the objectives set in the National NRHM document.
Achievement of these goals / outcomes will depend on several
intermediate outcomes, the major ones being:
• Complete immunization rates for children increase from current
level of 40% to 75% by 2012.
• At least 36% of Community Health Centres are upgraded to meet
IPHS by 2008 and 100% by 2010.
• 170 Comprehensive Emergency Obstetric Care institutions are
strengthened and made functional, 40% by 2006, 55% by 2007,
75% by 2008 and 100 % by 2009 and 500 Basic Emergency
obstetric Care institutions are strengthened and 40% made
functional by the year 2006, 50% by 2007, 60% by 2008, 80% by
2009 and 100% by 2010.
• The proportion of institutional deliveries is increased to 50% by year
2007, 65% by year 2008 and 75% by year 2009.
3.3
These goals / intermediate outcomes will be achieved by restructuring
and improving the functioning of the health systems as measured by
the following indicators:
• The public health facilities, especially in harder to reach areas, are
fully staffed, have requisite buildings and equipment and have
adequate resources for providing notified essential preventive
and simple curative services as per agreed standards of quality.
• Health systems are redesigned to ensure that the barriers to
access of services by the poor and vulnerable are removed;
poor are protected from the financial and social consequences of
illnesses; and inequalities in health outcomes are reduced as per
targets.
• Public expenditure on health is increased as per agreed targets
and it is allocated to levels (primary/secondary/tertiary), schemes
6 Specific targets will be set once funds availability and its prioritisation are finalised.
10
•
•
•
•
•
•
•
and programmes and regions, based on objective analysis of
information on cost-effectiveness and benefit-incidence.
Improved decentralization of planning and management of Health
services through district / sub-district level planning and
management in consultation with community and PRIs.
Community level trained health workers provide basic preventive
care at the community level and are supported by the referral
system for curative needs of the public. The paramedic staff is
capacitated to play a major role in delivery of preventive and simple
curative services at the SHC and PHC level.
Productive partnerships are developed with the private sector
for improving access of public to essential services and for
harnessing efficiencies of the private sector.
The provision of health services by the private sector (both large
hospitals and RMPs) is effectively regulated to ensure that its
reach is improved and public receives quality care at reasonable
costs.
Risk pooling mechanisms are piloted and successful models are
up-scaled to ensure that the health care markets gradually move
away from reliance on out of pocket expenses; and purchaser and
provider functions are separated for better efficiencies.
The management of human resources in the public health sector
is improved so that staff is motivated to perform and is held
accountable (internally and externally) based on performance. This
will be achieved through career planning, sound policies for posting
and clearer authority-responsibility descriptions at all levels.
Health management Information systems enable disaggregated
analysis of health situation and performance of health systems
which enable better monitoring and evaluation and evidence
based planning
11
4.0
Policy and Strategy Context
4.1
GOI Policies
GOI plays a key role in influencing and setting the direction of health
policies and strategies due to presence of large number of central and
centrally sponsored schemes. So far, these schemes have focused
primarily on technical strategies (and finances) for addressing key
public health challenges - maternal and child health, population
stabilization and major communicable diseases such as TB, Malaria
and HIV/AIDS. These strategies and schemes have had a limited
impact as they did not address the core problems that are affecting the
delivery of health services in general and of public health care delivery
in particularly. These include, low public health expenditure, inequities
in access of health services, poor quality and accountability of public
services, weak regulation of private sector services, absence of risk
pooling mechanisms, weak links to other determinants of health, poor
quality of information systems and issues relating to Human resources
availability and quality.
4.2
NRHM and RCH
In the absence of a coherent and comprehensive strategy, various
health interventions and strategies have failed to deliver the desired
impacts. This is sought to be corrected by the recently launched
National Rural Health Mission (NRHM) that recognises that focus on
narrowly defined diseases control programmes and projects is not
sufficient to transform the public health system into an accountable,
accessible and affordable system of quality services.
NRHM (and RCH) have laid out the medium term strategic framework
for health sector reforms in the state that brings under its umbrella all
vertical disease control programme (RCH,TB,Malaria, Polio etc.)
except HIV/AIDS. More than this, it provides strategic direction for
correcting the architecture of public health service delivery up to the
sub-centre level. The main planks of NRHM strategy are:
• A cadre of community level health workers (ASHAs).
• District level planning and involvement of community and PRI
institutions in planning and monitoring of health services at the field
level.
• Substantial increase in public health expenditure - to raise it to 23% of GDP by 2012.
• Introduction of risk pooling mechanisms for protecting the poor from
catastrophic consequences of illnesses.
• More autonomous functioning of the public health facilities through
provision of untied funds at all levels and revitalising hospital
management committees that have participation of PRI institutions
on the management committees.
12
•
Restructuring of the health set up at the state level with merger of
the family health and family welfare functions.
The recently launched ROH programme has laid out key strategies for
MCH that include focus on institutional deliveries, public-private
partnerships, operationalising IMNCI, strengthening demand for MCH
services through community involvement and targeted BCC
interventions etc. An important feature of RCH programme is bottom up
planning and setting up of strengthened management structures at
state and district levels. GoMP has already signed an MOU with GOI
under NRHM agreeing to the core strategies and a 5 year project
implementation plan has been prepared. The PIP would be updated
next year based on district level perspective plans subsuming all
vertical disease control programmes.
4.3
State’s Recent Reform Initiatives
At the state level, higher allocation for public health, support for
decentralized governance, greater autonomy to hospitals through Rogi
Kalyan Samitis, thrust on district level planning and piloting of
insurance schemes for poorer groups have been the key reform
themes. State is committed to empowering the PRIs and its benefits
are visible in the education and ICDS schemes. The importance of
decentralized planning is further being reinforced by planning
commission with district plans being made mandatory for preparation of
the Xlth plan. However, roles and responsibilities of PRIs in planning
for and managing of health services need to be more clearly defined to
improve the accountability and responsiveness of the delivery system.
MP has been the first state to have developed district health plans,
which have enabled districts to assess their own situations and
recommend priorities. The MP Health project supported by DFID
encouraged districts to try out innovations in service delivery and some
of these (such as Janani Express) have been extremely successful.
MP, again, was one of the first states to initiate hospital autonomy
through constitution of RKSs. Although, this model needs to be
improved along many dimensions (improved targeting of the poor,
better utiilisation of funds), it has provided much needed financial
flexibility to field units. State expenditure on public health, which is
0.9% of GDP at present, is committed to grow at 10% p.a., which
together with higher allocations from GOI should help strengthen the
public health system.
Convergence of schemes, which address the problems that have a
determining influence on the health status, has been given due priority
by the state. State is striving hard to address the issues of rural poverty
through initiatives such as Rural Employment Guarantee Scheme,
MPRLP (DFID supported) and DPIP (supported by the World Bank).
Schemes such as ‘Swajaldhara’ are being implemented to improve
13
water availability and hygiene practices in rural areas and issue of
malnutrition is being actively addressed through schemes such as
Balsanjivani and Balshakti. Implementation of these schemes needs to
be coordinated for optimising their impact on health outcomes.
The state health reform strategy and programme will, therefore, need
to be finalised within the above framework of national and state policies
and priorities.
14
5.0
Health Sector Reform Strategy
The implementation of the vision of the government to provide
accessible, affordable, equitable, accountable, effective and quality
health care, especially to poor and vulnerable sections of the
population will require significant strengthening of the health systems.
The strategy will have to address constraints on demand and supply
side and the working of health services market. The generic problems
that the strategy will need to address are:
(a) Demand Side: improving health-seeking behaviour, ensuring that
social and financial barriers to access of services are removed and
greater community engagement in primary health services planning
and delivery.
(b) Supply Side: higher public expenditure on health prioritised in
favour of primary care and poorer regions, filling up of gaps in
primary and secondary health infrastructure, addressing gaps in
human resources, improvement in performance, quality and
accountability of services, better coordination with the private
providers; and improved health information system.
(c) Health Care Market - effective stewardship of the private health
care market, knowledge creation and dissemination and promotion
of risk pooling mechanisms.
The health sector reform strategy addresses these core issues and is
based on the following principles:
• Strategy is to be consistent with the national and state policies,
especially the policies laid down in NRHM and ROH.
• Government will have to play a key role in ensuring provision of
basis health services. However, wherever possible, efficiencies of
private sector may be tapped for actual delivery of services.
• Although, strategy will seek to address the issue of attainment of
health related MDGs, removal of inequities in access to health
services and health outcomes will be a key objective.
• Decentralization of planning, monitoring and management of health
services will be a key plank of the strategy.
• All determinants of health need to be addressed in a convergent
manner for effectively addressing the health challenges in the state.
In line with the above the key approaches to reform of the health sector
will include:
• Programmatic - choice of basic package with focus on needs of
the poor and vulnerable, provision of physical infrastructure and
drugs, especially in poorer regions, effective referral system,
approaches to resource allocation, communication strategies, and
contracting for service provisioning.
15
Governance
Changing
institutional
arrangements
(decentralization, community participation, hospital autonomy,
public private mix) for improving responsiveness and accountability,
improved capabilities for policy making, planning and for financial
management and procurement, health information systems,
convergence with other determinants of health, and stewardship of
the private sector.
• Organisational - Reorganising of health services at the state and
filed level, skill-mix and skill up-gradation of work force, human
resource development, adequacy of manpower especially in
vulnerable regions.
•
Health Financing - raising public expenditure on health, reducing
financial barriers to accessing basic health services, risk pooling
mechanisms for the poor and better targeting of resources.
These strategic components are discussed below.
•
5.1
Programmatic Reforms
(a) Essential Services at SHC, PHC and CMC level
State is committed to provide preventive and curative services to its
people. In order that the health facilities ate appropriately resourced
and optimum utilisation is made of available funds and
infrastructure, and service delivery at the facility level adheres to
standards, state will:
• Determine list of preventive and simple curative services to be
provided at SHC, PHC, CHC level. This will be determined on the
basis of study of the burden of disease, disaggregated by regions
and by socio-economic groups, and cost-effectiveness of
services keeping in view the health needs of the poor and the
vulnerable. The (draft) IPHS standards, agreed MCH and
population control strategies and standard treatment protocols
will guide the determination of these essential services.
• Notify policy regarding payment for these services; groups that
will be exempted from payment (of specified services); and how
will exemption schemes work.
• Publicise nature of services provided and standards of service
quality ate various levels (for example, as Citizen Charter) and
institutionalise methods for periodic surveys of quality of services.
Results of these surveys will be disseminated to public.
• Pilot Quality Assurance Programs through external evaluations.
(b) Maternal and Child Health; and Population Stabilization
State will broadly follow the strategies recommended in the RCH
programme to address the issue of high MMR and gender
equity. These will include:
• Promotion of institutional deliveries, to be achieved by:
16
•
•
•
o Strengthening public facilities to provide emergency obstetric
care services to promote institutional deliveries.
o Develop competencies for SBA amongst ANMs, LHVs and
staff nurses.
o Contracting with private providers wherever possible for
providing EmOC services.
o Addressing the demand side constraints through household
level counselling by ANMs and ASHAs, financial incentives,
schemes such as Janani express and BCC
Strengthening of antenatal and postnatal care by improving the
functioning of sub centres, through effective integration of
ASHAs with the primary care delivery system and targeted BCC
interventions.
Stringent check on female foeticide (in the state and more
specifically in certain districts) through preparation and
implementation of District-specific action plans for effective
implementation of statutory provisions, coordination with the
community, NGOs and medical fraternity, and targeted IEC.
Promotion of safe abortions through:
o Preventive actions by effectively meeting the unmet need for
contraception and by checking sex selection practices.
o Expansion of safe abortion services which are accessible,
and ensure privacy
o School / College education programmes linked to ARSH
o Training of local providers
Strategies for improved health status of children will include:
• Universalization of routine immunization through:
o Improved coordination between ANMs, AWWs and ASHAs.
o Improved availability of vaccines through piloting alternative
vaccine delivery mechanisms.
o Better data collection and monitoring systems
o Social awareness programmes
• Strengthening Neonatal care units at PNC level.
• Strengthening approaches for management of diarrhoea, ARI
and for promotion of Breast feeding
• Management of severe malnourished children through schemes
such as Bal Shakti.
• Implementation of IMNCI
• School Health programmes
The population stabilization programme will focus on meeting the
unmet need for contraception through aggressive use of social
marketing techniques, promotion of male vasectomy through NSV
procedures, effective implementation of ARSH; and above all
through extensive BCC and convergence with other programmes
targeting early marriage, women empowerment and female literacy.
17
(c) Strengthening of Public Health Infrastructure
The key actions for improved availability of primary and secondary
health facilities will include:
• Construction of 4911 SHCs, 450 PHCs and 120 CHCs in a
phased manner with priority given to vulnerable regions.
• Upgradation of CHCs to IPHS standards in a phased manner.
• Upgrading infrastructure in all CeMOCs and BeMOCs on the
basis of a facility survey.
• Provision of untied funds to health facilities for improving
flexibility in their operations.
• Mobile clinics to cover inaccessible areas.
• Revamping of drug procurement and distribution arrangements
on the pattern of Tamilnadu. This will involve review of essential
drug lists, newer methods of procurement, construction of stores
and training in management of drug procurement, storage and
distribution.
• Rationalization of the working of the subcentres and PNCs. At
the sub-centres, provision of two ANMs and at the PHC level
multi-skilling of work force to ensure that PHCs are able to
provide a basic minimum level of service on a regular basis
would be experimented with.
• Provision of adeguate number of staff - this is the key constraint
at present and has been discussed in detail as a part of the HR
strategy.
The strategy for filling up of infrastructure gaps will focus on the
gaps in tribal and other areas where access is poor and availability
of human resources will be ensured for optimum utilisation of
facilities.
(d) Disease Control programmes
The focus will be on TB and malaria and effective implementation of
national programmes targeting these. Vector control programmes
will be integrated into village health plans, social marketing of bed
nets will be given a priority and systems for surveillance will be
strengthened. As regards TB, focus will be on improving detection
rates and linking with private providers to ensure that they follow the
prescribed protocol. The HIV programme will be implemented as
per NACP strategies and focus here will be on strengthening of
sentinel surveillance,
making
HIV control an
area of
interdepartmental convergent action and expanding programme of
targeted interventions and VCTCs.
18
(e) Contracting with Non Governmental sector for provision of primary
health care services:
In order to fill gaps in access and availability of primary and
secondary health services and also for capturing the efficiencies of
non governmental sector working, both contracting-in and
contracting-out of public health services will be piloted and if
successful, up-scaled. Contracting will also enable state to
rationalize manpower by redeploying human resources to places
where private sector is not available.
(f) Behaviour Change Communication:
Changes in health habits and attitudes at the family and community
level are reguired for improving the health outcomes. Issues relating
to age of marriage, planning for the family, use of antenatal and
postnatal care, child- care practices, gender equity, hygiene
practices etc require changes in behaviour and attitudes. BCC
strategies will be developed at the regional and district level to
ensure that they meet local needs. There will be emphasis on
development of capacities at the state and district level in
developing and delivering sound communication strategies and to
monitor the efficacy of BCC plans.
(g) Strengthening Referral System
The tertiary care institutions provide vital support to primary and
secondary health care facilities. The medical colleges will be
strengthened to develop strong referral and back-referral system.
The district hospitals will be strengthened to support PHCs and
CHCs and to reduce burden on medical colleges. Here also, links
will be developed with the private sector, wherever possible, to
supplant public facilities.
5.2
Reforms in Governance of Health Systems
Improvement in capacities for better planning, management and
delivery of quality health services and improved responsiveness and
accountability of the public health system will be achieved through
decentralization, community participation, strengthening of institutional
set up and better health monitoring systems. Reorganisation of the
public health set up, organisational development and review of HR
practices are a part of overall governance improvement but have been
discussed separately.
(a) Decentralization
For health services to be responsive to local needs in a cost
effective manner, planning and delivery of these services needs to
be decentralized. This will include decentralization of decision
making and enhanced delegation and autonomy at the operating
level.
19
State has made a good beginning in preparing district plans taking
care of local needs. District Planning processes will be
strengthened by creating capacities for better collection,
management and analysis of disaggregated data and in use of
epidemiological insights for district level burden of disease studies
for preparing more responsive plans. PRIs and local NGOs/CBOs
will be involved intensively in the District planning processes that
will be supported by providing technical assistance and also by the
state resources centre. Few initiatives are underway for preparation
of Village Health plans. These will be up-scaled gradually to
prepare integrated village health and sanitation plans, which will
ultimately be linked up with district plans. However for services to
improve, decentralization has to move beyond planning. First,
untied funds would be provided to districts to plan and innovate
taking into account local needs and second, decentralization of
powers to local government structures will be made to ensure that
delivery of primary health care is gradually managed at local level.
Strengthening of Rogi Kalyan Samitis will be a key strategy for
improving hospital autonomy. The organisation and structure of
RKS will be reviewed to ensure that the local community and PRIs
have a more effective say in running of the RKS. RKS will be
provided technical support for preparing long term plans for bringing
their facilities up to agreed standards (fro example, IPHS),
improving systems for better utilisation of funds in a pro-poor
manner, and also financial support to take care of the exemptions
given to poor.
(b) Community Participation
Community involvement and participation would be a key to meet
the public health challenges. Para professionalisation of primary
health care services will be the key strategy to achieve this. State
has already begun recruitment of ASHAs to prepare them to play a
key role in providing community / household level preventive care.
However, state’s experiences with the Janswasthyay Rakshak
scheme suggests that for ASHAs to be effective, action on following
lines will need to be taken:
• Supporting ASHAs for them to be recognised as a vital link in
addressing primary health needs of the community.
• Effective institutional linkages and referral mechanisms between
ASHAs and the existing set up of primary health workers and
facilities.
• State level structures to plan for the capacity building to be
delivered through block / level set up supported by NGOs.
• Proper systems for monitoring and ensuring that ASHAs remain
motivated to perform and retain their knowledge and skills.
20
Community participation in selection and control over ASHAs and in
preparing village health plans will be further reinforced by
introducing community monitoring of delivery of health services
and social audits. These measures will likely make the public health
care system more accountable. Collaboration with NGOs will be
actively sought to support capacity building of communities for
effective participation.
(c) Improved Health Management Information System (HMIS) and
Monitoring
Ensuring availability of guality and timely information and its proper
dissemination will enable better planning at state and district level,
will result in higher transparency in the working of public health
facilities and make them more accountable.
Strengthening of HMIS at all levels to provide disaggregated data
on health status and geographical and social distribution of health
problems will be a key priority of the programme. A situation
analysis of the existing HMIS will be made leading to review of
formats, data capturing methods and, as per requirement, setting
up of the IT infrastructure. The HMIS will be linked to the district
level disease surveillance systems and with progress on social
determinants of health to enable more convergent planning and
management. The key would be to ensure that HMIS not only
results in better supervision but it also supports the filed staff in
planning and managing their work better.
The monitoring and supervision systems will be revamped by
developing key performance indicators (KPIs) that will focus on the
attainment of health policy goals and especially the goals relating
to reducing inequities in health status across regions, socio
economic groups and gender.
Qualitative and participatory
techniques for monitoring will be introduced and community
monitoring processes will be set up. The mechanisms of periodic
surveys of health facilities to monitor service adherence to service
standards, formation of Health Monitoring and Planning
Committees at SHC, PHC, CHC and District level and preparation
and dissemination of public reports on health will be piloted for
improved monitoring. These will be supplemented by external
surveys and impact evaluation of major schemes and
programmes.
Health management and monitoring information will be widely
disseminated. Public disclosure of information on health system
performance will inform the public and community to monitor
service standards and hold government to account for
deficiencies; and better monitoring of social inclusion.
21
• Decentralization - Functional review of health planning and
management systems to decentralize decision making to PRIs with
provision of untied funds.
• Capacity building of the community for preparation of Village Health
and Sanitation plans.
• Community involvement in planning and management of health
services
o Village Health and Sanitation Plans
o Control over ASHAs
o Community Monitoring and Audits.
o Community-managed support systems such as emergency
transport schemes and emergency funds. This will also bridge
• Social Mobilisation programme to increase women to women peer
support, engaging respected traditional practitioners, and building on
traditional practices to elicit community support for maternal and
child health care practices.
6.7
Monitoring of EAR
Specific time-bound milestones will be developed for various priorities
listed in the EAR and these will be monitored on a quarterly basis by
the government. State will also institutionalise systems for independent
external assessment of the working and impact of major schemes and
programs.
32
u
(1
T)
2005 -2i3«
I? . :
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[iw]
'3
:,«W
NATIONAL RURAL HEALTH MISSION
Meeting people’s health needs in rural areas
Programme Implementation Plan
2006-2012
State Health Mission
Department of Health & Family Welfare
Government of Madhya Pradesh
Bhopal
1
u
TABLE OF CONTENTS
Timelines for NRHM Milestones
3
1.
Background
7
2.
Situational Analysis
10
3.
Vision, Goals, Objectives and Envisaged Outcomes
21
4.
Critical Areas for Concerted Action
28
5.
Broad Framework for Implementation
31
6.
Core Strategies and Programme Implementation Plan
45
Abbreviations (Annexure-ll)
67
2
11 •
i. TIME LINE FOR NRHM MILESTONES
S.
No.
Milestone
1
Selection of Accredited Social Health
Activist
(ASHA)
for
every
1000
Phasing and
time line
40% by 2006 i.e.
Means of
Verification
Quarterly
17565 ASHA
Progress Report
population/large isolated habitations in
all 48 districts- 43913 ASHAs in the
70% by 2007 i.e.
State.
30742
100% by 2008
i.e. 43913
2
Fully trained ASHA workers
40% by 2007 i.e.
Quarterly
17565
Progress Report
80% by 2008 i.e.
and sample
35130
verification
100% by 2009
i.e. 43913
3
>
>
3% by 2007 i.e.
Quarterly
Committee constituted in all 52143
1565
Progress Report
inhabited villages
25% by 2008 i.e.
Untied grants provided to them
11470
Village
Health
and
Sanitation
> Village Health & Sanitation Plans
prepared for local health action.
50% by 2010 i.e.
13036
100% by 2012
4
>
ANM
State reports,
District Action
Plans.
Facility Surveys
and External
assessments
Centres
7% by 2007
strengthened to provide service
25% by 2008
guarantees as per IPHS, in 8835
47% by 2009
places upto year 3, 2 ANMs in
69% by 2010
10493 SHCs from year 4 onwards.
100% by 2012
Untied grants provided to each
100% each year
State Reports
500 BEmONC facilities (including
40% by 2006 i.e.
Annual Facility
8 Civil Hospitals, 178 CHCs and
200 BEmONCs
Surveys. External
314 PHCs) strengthened with 3
50% by 2007 i.e.
assessments
Staff Nurses to provide service
250 BEmONCs
> 2
Sub
Health
Sub Centre for promoting local
health action.
5
>
3
- I i
S.
No.
guarantees as per IPHS.
Phasing and
time line
60% by 2008 i.e.
Untied grants provided to each
300 BEmONCs
facility for promoting
80% by 2009 i.e.
Milestone
>
BEmONC
Means of
Verification
400 BEmONCs
local health action.
100% by 2010
i.e. 500
BEmONCs
6
Annual activity
State report
124 CEmONC institutions (32 CHs
40% by 2006 i.e.
Annual Facility
and 92 CHCs) strengthened with 7
50 CEmONCs
Surveys.
Specialists and 9 Staff Nurses to
55% by 2007 i.e.
External
provide service guarantees as per
68 CEmONCs
assessments.
IPHS.
75% by 2008 i.e.
Untied grants provided to 1152 PHCs
and 266 CHCs for promoting local
health action.
7
>
93 CEmONCs
100% by 2009
i.e. 124
CEmONCs
8
48 District Hospitals strengthened to
30% by 2007 i.e.
Facility Surveys.
provide quality health services.
15 DH
External
60% by 2009 i.e.
assessments.
30 DH
100% by 2010
i.e. 48 DH
9
>
Rogi Kalyan Samitis established in
all
>
PHCs,
CHCs/Civil
100% District
State report.
Hospitals, Civil
Hospitals/District Hospitals.
Hospitals and
One time support to RKSs at
CHCs; 50% of
PHCs/CHCs/Civil Hospitals/District
PHCs by 2006,
Hospitals.
100% PHCs by
2007
11
>
District Health Action Plans 20052012 prepared by each of the 48
100% by 2007
Appraisal process
with participation
4
II
S.
No.
Milestone
Phasing and
time line
Means of
Verification
of DPs and Gol
100% by 2007
representatives
100% by 2007
State reports
100% by 2007
Regular meetings
districts.
>
District Health Plans reflect the
wider
with
convergence
determinants of health like drinking
water,
women’s
sanitation,
empowerment, child development,
school
adolescents,
education,
female literacy, etc.
12
Annual maintenance grant provided to
every Sub Centre, PHC and CHCs.
13
State and District Health Societies
and sample
established and fully functional.
verification
14
State and district PMUs staff receives
100% by 2007
State reports
None by 2006
Independent
10% by 2007
assessment
training.
15
Sample districts able to implement
triangulation
M&E
involving
community.
25% by 2008
50% by 2009
100% by 2010
16
100% by 2007
State reports
Hospitals/
30% by 2007
State reports
District Hospitals fully equipped to
60% by 2008
health
sector
100% by 2009
coordination
and
Procurement and logistics streamlined
to
availability
ensure
of
100%
availability of at least one month’s
stock
of
essential
drugs
and
medicines at Sub Centres/PHCs/CHs/
CHCs.
17
SHCs/PHCs/CHCs/Civil
develop
intra
convergence,
service guarantees for family welfare,
vector borne disease programmes,
TB, HIV/AIDS, etc.
18
Districts constitute Quality Assurance
100% by 2007
State reports
5
S.
No.
Phasing and
time line
Milestone
Means of
Verification
Committees.
19
Facility and household surveys carried
20% by 2007
out in each and every district of the
100% by 2008
Survey reports
State.
20
30% by 2008
Independent
60% by 2009
100% by 2010
assessment.
of
50% by 2008
Independent
performance against assured service
70% by 2009
assessment
guarantees carried out.
100% by 2010
Mobile Medical Units provided to each
30% by 2007
Quarterly
district of the State.
60% by 2008
100% by 2009
Progress Report
Annual
State
and
District specific
Public Reports on Health published.
21
22
Institution-wise
assessment
Note : ‘Year’ refers to financial year ending 31st March.
6
II
1. BACKGROUND
1.1
Demographic and Socio-economic Features
Madhya Pradesh, as its name implies, is located at the geographic centre of India. It
shares its border with five states, namely, Maharashtra, Gujarat, Rajasthan, Uttar
Pradesh, Chhattisgarh, Covering an area of 308,000 square kilometers with the
population of 60.4 million, it has a large proportion of scheduled castes and tribes
(15.4% and 19.9% respectively) with 73% of the population living in rural areas.
Despite significant progress in socio-economic development over the last decade, the
State continues to be afflicted with some of the worst indicators in India. These include
low literacy rates, especially female literacy, high levels of morbidity and mortality and
37% of the population lying below the poverty line.
89% of the population in rural
areas is dependent on agriculture. The State is typically characterized by difficult
terrain, high rainfall variability, uneven and limited irrigation, deforestation and land
degradation.
SOCIO-DEMOGRAPHIC PROFILE
INDICATORS
Area (In sq. km)
M.P.
India
3,08,245 (9.38% of
32,87,263
India’s total area)
Population (Census 2001)
6,03,85,118 (5.88% of
1,027,015,247
India’s population)
Population growth rate (1991-2001)
Population density
24.34
196
21.34
324
~ 64.11
65.38
76.80
75.85
• Female Literacy
Sex ratio (Females per 1000 Males)
50.28
920
54.16
933
Urban population
26.67%
27.78%
Scheduled Castes
74, 78,000 (15.4%)
16, 65, 76,000
Scheduled Tribes
96, 82,000 (19.94%)
(16.20%)
8,31,88,235
498
(8.10%)
407
79/1000
64/1000 (SRS 2004)
3.3
2.9
Literacy Rate
•
Male Literacy
Maternal Mortality Rate (SRS 1998)
Infant mortality rate (SRS 2004)
Total Fertility Rate (NFHS-II)
7
1.2
Age Distribution
The age distribution of the population in Madhya Pradesh is typical of populations in
which fertility has fallen recently, with relatively low proportions of the population in the
younger and older age groups. 39 percent are below 15 years of age, and 5 percent
are aged 65 or older. The proportion below age 15 is higher in rural areas (40 percent)
than in urban areas (35 percent), primarily because fertility is higher in rural areas.
Age & Sex composition of Population - 2001
Madhya Pradesh
EH
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'0^
|G5-69|
,i m
i
,_____
Male
Female
EHEEl
SEE __ ZZ
__________ BE] ’_________
EED
ii
f
8
1.3
6
4
2
o
:2
4
6
8
Density of Population
Population density per square kilometer has increased from 158 in 1991 to 196 in
2001. Although the population density in Madhya Pradesh remains low relative to most
other large states, the rising density indicates an increasing pressure on land and other
resources.
1.4
Literacy Rate
According to the 2001 Census, literacy rate for Madhya Pradesh was 64.08 percent
compared with 65.38 percent for India as a whole. The literacy rate for males was
76.50 percent and only 50.55 percent for females in Madhya Pradesh. Compared with
the literacy rate of 1991 (44.67), there has been a considerable improvement in the last
8
ten years. There has been a greater improvement in the female literacy rate as
compared to the male literacy rate. Education levels are much higher in urban areas
than in rural areas. The proportion of illiterates is almost twice as high for rural females
(63 percent) as for urban females (33 percent), and nearly thrice as high for rural
males (34 percent) as for urban males (13 percent). Even in urban areas, however,
only about half of the males (47 percent) and slightly more than one-quarter of the
females (28 percent) of age 20 and above have completed at least high school.
Illiteracy was virtually the same for women in the age-groups 35-39 to 45-49 before
decreasing to 64 percent for women in age-group 20-24 and then rising slightly to 66
percent for women in age-group 15-19, undoubtedly because illiterate women are
more likely to get married than the literate women at a young age.
1.5
Below Poverty Line Population
According to the Third Madhya Pradesh Human Development Report (2002),
population Below Poverty Line (BPL) in 1999-2000 has been estimated at 37.43%
(37.06% for rural and 38.44% for urban). This figure is higher than the national average
of 26.10%. The Per Capita Income (calculated at constant prices, 1993-1994) for
Madhya Pradesh was Rs.7876/- in 1999-2000, being much lower than the National
figure of Rs.9739/- (Source: Dept, of Finance, GoMP). BPL population of 37% means
that about 22.60 million people are classified as poor. Regionally, there is less poverty
in the Gwalior region, western Bundelkhand and around Bhopal followed by moderate
levels in the Malwa region and extreme poverty in the eastern and Bundelkhand areas.
1.6
Administrative Profile of the State of Madhya Pradesh
Indicator/Parameter
Development Blocks
Tribal Blocks
No. of Towns/cities
No. of Municipal Corporations
No. of Municipalities
No. of Nagar Panchayats
No. of villages
No. of inhabited villages
No. Gram Panchayats
No. of Janpad Panchayats
No. of district Panchayats
Nos.
313
89
394
14
85
235
55392
52143
22,029
313
48
9
2. SITUATIONAL ANALYSIS
In this chapter, situation of health and its determinants has been reviewed with
reference to NFHS, RHS and such other reports. While the NFHS-2 provided state
level estimates, the RHS estimates are available at the district level. Data from these
sources have been compiled by select background characteristics such as residence,
caste and standard of living (SLI), in addition to analyzing the results from a qualitative
study of RCH programme that was carried in the three regions of the state. All these
results have been put together and presented in the following sections.
The current levels of major indicators are summarized in the following table:-
Sr.No
1
2
3
5
6
7
8
9
10
11
12
13
14
| Indicator
_____________________ Maternal Health
Percentage of pregnant women registering in
first trimester___________________________
Percentage of pregnant women receiving full
ANC care_____________________________
Percentage of deliveries attended by Skilled
Birth Attended__________________________
Percentage of Home Deliveries___________
Percentage of Institutional Deliveries_______
______________________ Child Health
Percent of children who were exclusively
breastfed for four months________________
Percent of Children ( 12-23 months) fully
immunized____________________________
Percent of Children suffered from Diarrhea
Percent of Children suffered from ARI______
_____________________ Family Planning
Met need for FP method among eligible
couples____________________________ __
Unmet need for Spacing method__________
Unmet need for Limiting method___________
Contraceptive prevalence rate____________
Total demand for FP services
| Current Status
26
51.2
30.0
79.0
21.0
36.5
22
23.4
29.2
44.3
8.9
7.3
42.0
60.5
MATERNAL HEALTH
Antenatal Care
It can be seen from the following Table that while 6 out of ten women availed antenatal
check-up, more than half received two or more tetanus toxoid injections and 8 out of 10
women have received IFA tablets or syrup during pregnancy for three or more months.
10
Only one third of the pregnant women received more than 3 ANC check ups. The
service utilization is better in urban area as compared to rural area.
Percentage of women receiving various types of ANC care
Indicator__________________________
Women receiving any ANC check up
Women without any ANC check up
Women receiving 3 ANC check ups
Women receiving 2 or more doses of TT
Women receiving more than 100 IFA
tablets
Urban
Rural
Total
82.1
17.9
51.2
55.8
44.2
21.8
49.8
79.3
61.5
38.5
28.1
55.0
78.4
73.7
76.2
Delivery Care: Place and Assistance during Delivery
It indicates that eight out of 10 deliveries in Madhya Pradesh state are taking place at
home and the remaining two deliveries either in public or private institutions.
In urban
areas half of the deliveries are in institutions while it is less than 1 out of 10 deliveries
in rural areas. It is also seen that the proportion of deliveries attended by the health
professional like Doctor, Staff Nurse or ANM is very high in urban area as compared to
rural area. Half of the Home deliveries are attended by Traditional Birth Attendants.
Details of place of birth and assistance during delivery
Indicator_____________________
Home Deliveries_______________
Institutional Deliveries__________
Deliveries attended by Doctor
Deliveries attended by Nurse/ANM
Home deliveries attended by TBA
Urban
Rural
Total
50.1
49.1
40.3
20.8
29.1
86.5
12.1
12.5
8.2
51.6
78.7
20.1
19.0
11.0
46.7
However, it may be mentioned here that with the introduction of schemes like Janani
Suraksha Yojna, Prasav Hetu Parivahan Yojna and Vijaya Raje Janani Beema Kayan
Yojna, there has been a clear spurt in institutional deliveries in the State. The State
reports indicate that the institutional deliveries, which stood at 25% in April 2005 has
gone up to 47% in September 2006.
Anemia among Women
The nutritional status of women in the state is low. Overall, 54 percent of women in the
state have some degree of anemia, compared with 52 percent in India as a whole.
About 16.6 percent of women in Madhya Pradesh are moderately to severely anemic.
The percentage of anemic women is much higher in rural area as compared to urban
area.
11
Prevalence of RTIs
The NFHS-2 depicts that four out of 10 currently married women have reported of at
least one reproductive health problem. The common problems reported were abnormal
vaginal discharge and symptoms of urinary tract infection. Rural women reported of
these problems more frequently than their urban counterparts. Only 3 out of 10 women
suffering with RTI/STI symptoms availed treatment.
CHILD HEALTH
The reproductive health survey collected information on child immunization, reasons
for not availing child immunization services, and breast-feeding and weaning practices.
This apart, the NFHS-2 has provided levels of infant and child mortality and the
nutritional status of children at the state level.
Infant and Child Mortality
The NFHS-2 survey conducted in 1998-99 estimated the Infant Mortality Rate (IMR) to
be 86 deaths of infants per 1,000 live births during the four years preceding the survey,
much higher than the IMR of 68 in India. The Child Mortality Rate (CMR) in the state
was 56 (deaths of children aged 1-4 years per 1,000 children reaching age one). In all,
among 1,000 children born, 56 die before reaching age five. As expected, IMR in rural
areas was higher than urban areas.
Child Immunization
Immunization of children is an important component of child-survival with efforts
focusing on six childhood diseases of tuberculosis, diphtheria, pertusis, tetanus, polio
and measles.
The objective of Universal Immunization Programme (UIP) was to
extend immunization coverage against these diseases to at least 85 per cent of infants
by 1990, and the target now is to achieve 100 per cent immunization.
However, in
Madhya Pradesh, only 22 per cent of children aged 12-23 months were fully
vaccinated; about 64 per cent had received some, while the remaining 14 per cent had
not been vaccinated at all. Dropout rates for the series of DPT and polio vaccinations
were also a problem. Sixty three per cent of children received first dose of DPT, but
only 37 per cent received all three doses. Likewise, 85 per cent of children received
first dose of polio but only 56 per cent received all the three doses.
Coverage of
measles was 35.6 per cent.
12
Infant Feeding Practices
Practice of breastfeeding is very poor in Madhya Pradesh. The NFHS-2 indicated that
less than one-tenth of children were breastfed within an hour of birth and less than one
third in the first day.
Further, for 71 per cent of mothers squeezed out the first milk
from the breast before feeding the baby, contrary to recommended feeding practices.
Only one third of the children of less than four months of age were exclusively
breastfed. The median duration of exclusive breastfeeding is only 2.6 months.
Diarrhea & ARI
Awareness and Treatment of Diarrhea
Only one third of the mothers were aware of two or more danger signs of diarrhea.
About one-fourth of the children in the state had suffered from diarrhea in the two
weeks preceding the survey (NFHS-2). Of them, 60 per cent of mothers reported
having taken their child/children to a health facility or health-care provider but only 55
percent of mothers used ORS during the diarrheal episode.
Awareness and Treatment of ARI/Pneumonia
According to the NFHS-2, 31 per cent of children under age three were ill with fever
during the two weeks preceding the survey and 29 per cent were ill with ARI.
Fifty
eight per cent of children who were ill with ARI were taken to a health facility. The
prevalence was substantially higher in rural areas in comparison to urban areas.
FERTILITY AND FAMILY PLANNING
The levels of fertility and contraceptive use have been compiled using the NFHS-2
survey reports
Fertility
The State of Madhya Pradesh has a total fertility rate (TFR) of 3.31 still on a higher
side required for replacement level fertility. The TFR in urban area is (2.61) lower as
compared to rural area where it is 3.56. Among the women age 15-49, the mean
number of children ever born is 2.8 for all women and 3.3 for currently married women.
The mean number of children ever born increases with increasing the age and it is 5
for the age 45 -49. About thirty five percent of the women have birth order more than 4.
13
Contraceptive Prevalence
The awareness regarding the modern contraceptive methods is very high but the
modern contraceptive prevalence in Madhya Pradesh according to the NFHS-2 was 42
per cent. Female sterilization as expected turned out to be the more popular method
with about 35 per cent of currently married aged between 15 and 49 years accepting it.
This was followed by condoms (3 percent), IUCD (0.8 percent) and oral pills (1.0
percent). The use of spacing methods was negligible. Contraceptive use increased
with the number of living children and specifically with the presence of a son. Analysis
by
background
characteristics of residence,
caste
and
SLI
depicted
higher
contraceptive prevalence among urban women (52 percent) in comparison with rural
women (39 per cent).
Unmet Need for Family Planning
Currently married women who are not using any method of family planning but also do
not want any more children or want to wait two or more years before having another
child, are considered as having an unmet need for family planning. Current
contraceptive users on the other hand are said to have a met need for family planning.
The total demand for family planning is the sum of met and unmet needs. The need for
spacing or limiting births depends upon, whether or not a woman wants to have a child.
This concept helps in understanding the potential demand for family planning and
facilitates in converting this potential demand to real demand.
The following table summarizes unmet need, met need and demand for family
planning. The total unmet need in the state was 16 per cent and the unmet need for
the spacing method was slightly higher than that for the limiting method. The unmet
need was lower in urban areas than in rural areas.
Need for Family Planning Services
Indicator_____________________
Met need for Spacing Method
Met need for Limiting Method
Unmet need for Spacing Method
Unmet need for Limiting Method
Total Demand for Spacing Method
Total demand for Limiting Method
Total demand for FP services
Source: NFHS-2, 1998-99
Urban
Rural
Total
4.1
51.0
7.9
7.6
12.0
58.6
70.6
1.6
39.1
9.3
7.2
10.8
2.2
42.1
8.9
46.3
57.1
7.3
11.1
49.4
60.5
14
District Variations: (RHS-2202) The districts differ in their current status and
performance. Districts like Jhabua, Shahdol and Sidhi are showing very low level for
ANO check ups while the districts having the highest percentage of home deliveries
are Sidhi and Shahdol. Districts like Vidisha, Jhabua, Panna, Chhatarpur and Satna
show very low percentage of eligible couples using modern contraceptive method. The
table below presents the current status of the various indicators across different
districts:
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Indore
13.4
14.6
65.6
17.5
49.6
20.3
57.1
22.8
76.3
52.5
Dhar
14.6
4.6
27.9
0.9
38.1
29.0
21.0
27.0
52.0
53.2
Jhabua
25.6
4.9
26.2
1.3
24.8
21.2
14.7
22.8
63.3
54.1
Barwani
15.4
9.6
21.6
3.5
32.8
14.9
27.8
22.5
81.6
34.2
East Nimar
15.8
4.6
27.3
0.0
40.0
21.3
23.0
20.6
67.4
46.1
West Nimar
10.9
4.8
18.9
8.4
24.9
15.2
24.9
27.4
72.0
42.5
Ujjain
14.2
5.2
32.1
0.0
38.7
28.6
22.0
24.3
63.0
50.6
Dewas
16.9
2.5
31.7
2.7
36.1
21.9
24.9
26.9
61.0
58.3
Ratlam
17.3
6.1
25.7
0.0
42.8
22.1
32.9
16.6
70.3
27.6
Mandsaur
17.3
8.3
30.2
1.1
29.4
16.3
33.0
11.2
88.3
24.1
Shajapur
19.2
5.0
32.0
0.0
33.1
22.5
24.1
25.4
68.9
31.3
Neemuch
16.8
12.2
26.4
1.2
33.2
17.6
33.0
10.7
82.0
25.0
46.0
20.0
85.8
30.0
Bhopal
16.9
19.7
51.3
44.4
37.2
23.7
Sehore
20.3
3.1
30.7
4.2
21.3
31.1
33.3
31.3
63.2
66.8
Raisen
19.8
3.5
23.7
35.3
27.3
13.0
26.0
29.8
48.4
47.7
Vidisha
26.5
2.6
25.0
2.9
18.2
29.6
21.0
29.7
54.0
61.0
Betul
23.8
9.1
22.5
60.8
30.0
11.4
15.6
15.5
41.9
24.6
Rajgarh
19.8
3.3
35.9
8.3
26.0
13.8
31.9
18.3
71.5
30.8
Hoshangabad
14.4
9.0
36.8
9.6
66.5
25.9
22.6
8.7
59.9*
33.6
Harda
15.9
4.9
33.1
18.2
47.0
16.8
31.1
25.3
63.3
36.2
Jabalpur
16.9
13.2
42.4
5.1
50.2
11.5
43.3
19.5
68.3
27.6
Katni
23.6
2.5
18.9
7.3
39.3
22.1
20.4
15.6
61.0
31.3
Balaghat
20.6
15.2
21.5
47.7
48.2
7.2
27.4*
37.1
52.0
38.1
Chhindwara
17.4
6.1
25.9
39.6
46.8
26.8
27.9
42.2
57.7
30.1
Seoni
16.5
18.4
27.2
22.9
62.0
29.6
33.8
48.9
66.4
43.4
Mandla
15.8
2.8
20.2
24.1
55.8
19.6
17.7
25.3
33.6
42.0
Dindori
20.0
3.2
18.3
14.3
38.6
30.6
29.2
36.3
32.9
45.7
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27.3
36.5
48.3
49.1
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Narsimhapur
14.2
3.8
38.3
41.4
50.1
Sagar
27.3
6.5
22.5
50.8
31.7
12.9
19.7
16.4
80.0
42.5
16.4
18.8
46.3
26.9
46.2
30.6
Damoh
18.4
3.5
23.3
3.7
25.9
20.0
Panna
25.4
0.6
28.4
5.9
17.2
17.2
28.8
17.6
Tikamgarh
23.3
2.7
20.7
12.5
10.2
21.5
18.7
26.0
51.1
31.4
12.8
65.9
51.6
27.0
51.7
54.9
Chhatarpur
37.2
0.5
17.6
51.3
34.3
11.9
9.7
Rewa
31.0
4.5
22.4
19.5
35.2
19.3
14.3
Sidhi
38.8
0.8
6.2
79.1
10.7
0.6
59.4*
9.9
3.3
16.9
46.0
29.5
Satna
26.8
1.0
20.7
63.2
23.1
13.1
20.7
12.7
Shahdol
25.1
8.6
14.1
17.3
33.8
16.8
32.8
20.3
44.5
42.6
Umaria
26.5
6.4
27.5
21.7
21.1
29.2
32.4
24.0
55.4
40.8
Gwalior
25.0
4.6
47.5
40.9
35.4
5.9
13.8*
13.7
65.9
25.4
Morena
19.5
4.1
43.2
10.9
36.1
34.7
32.3
18.3
66.5
26.2
Sheopur
22.3
5.7
29.3
25.3
37.2
28.8
30.6
20.3
64.9
21.7
Shivpuri
18.8
1.7
28.3
0.0
19.4
11.3
10.8
10.0
31.7
27.2
Guna______
22.5
3.3
29.8
11.5
11.1
25.0
16.3
30.1
59.0
53.4
Datia
18.5
7.3
26.3
31.3
27.1
1-3.7
10.1
20.9
40.2
46.2
Bhind
30.6
1.5
23.5
6.5
14.0
16.3
12.9
15.1
75.2
35.3
Malaria
•
MP is one of the 3 worst malaria affected states. MP and Orissa alone account for
50% of mortality due to malaria in India (ICRIER, 2001).
•
Proportion of Plasmodium Falciparum malaria (associated with cerebral malaria
and with higher death rate) increased from 44 % in 1996 to 55 % in 1999. (source:
NMAP, MOHFW Gol data cited in ICRIER 2001).
•
Rural residents are twice as likely to suffer from malaria than urban residents
(10015 and 5240 respectively per lakh population - NFHS II).
Tuberculosis
•
The overall prevalence of tuberculosis (TB) increased by 21% during the period
1992-93 to 1998-99 (440 in NFHS I and 602 in NFHS II).
16
•
Prevalence of TB is higher in rural areas than urban areas (669 and 405 per lakh
respectively).
•
Prevalence is higher for males than females (678 and 519 per lakh respectively)
attributed to higher outside contacts of male population and their smoking habit.
Diarrhea
•
MP recorded the highest incidence of diarrhea in the country at 63 per 1,000 (as
per NCAER 1995 data cited in TARU report) and 28% of state’s IMR was due to
diarrhoeal deaths. Rajiv Gandhi Mission for Control of Diarrhoeal Diseases is
credited with contributing to the decrease of diarrhoeal deaths from 4387 p.a. in
1991 to 610 by 1997 (source: TARU report).
Nutritional deficiency
Nutritional deficiency is a major cause for concern in MP:
•
38% of women have chronic energy (nutritional) deficiency indicated by body mass
index (BMI)<18.5.
•
Anemia is higher amongst breastfeeding women (58%) than non-pregnant/non
breastfeeding women.
•
Anemia prevalence is higher amongst scheduled tribes (70.3%) (NFHS II).
Nutritional deficiency amongst children
Malnutrition of children and anemia increases susceptibility towards morbidity/mortality:
MP has the highest rate of undernourished children in the country:
•
More than 55% of children (6-35 months) are underweight due to chronic/acute
under nutrition.
51% are stunted due to chronic under nourishment/ recurrent diarrhea.
20% are wasted due to acute under nourishment or illness.
•
75% of children age 6-35 months have anemia; 53% suffering from acute anemia.
Gender Disparity
Women/girl children are distinctly worse off in MP:
•
Women have a limited role in key decisions related to maternal and child health:
only 37% of women take decisions affecting their healthcare and only 24% of
women discuss family planning with husband/somebody else;
•
Mortality rates for girls are higher than for boys except during early infancy when
girls have a biological advantage, as the following table shows:
17
Sex of child
NMR
PNMR
IMR
CMR
U5M
Male
67.3
29.8
97.2
49.4
141.7
Female
51.7
35.9
87.5
66.3
148.0
•
% of boys getting vaccinated (27%) was greater than girls (18%);
•
Boys are more likely to get at least one dosage (26%) than girls (23%);
•
16.5% of girls did not get any vaccination as compared to 11.5% for boys.
Health Status of Poor/Socio Economically Disadvantaged
The poor/socio economically disadvantaged are worse off in MP:
•
IMR is double and CMR is more than five times in poor families having a low
standard of living index;
•
12% of children in poor families were vaccinated compared to -50% for
economically better off families;
•
67% of deliveries in rich families were assisted by doctor/trained healthcare
personnel compared to 17% in poor families;
•
11% of ST children received vaccinations compared to 22.4% in total MP;
•
70.3% ST women suffered from anemia compared to 54.3% in total MP.
Water and Sanitation Services
Physical installation of water facilities (PHED data, April 2000) in MP is quite
impressive. 86% of a total of 111,780 habitations are fully covered (@ 40 Ipcd), 13%
are partially covered, while only 1% do not have any safe water source. There are
283,651 hand pumps, 2321 spot sources and 3589 piped water supply systems; 2-8%
of these installations are reported by PHED to be temporarily non-functioning due to
drying up of water sources, while 13% of installations are classified as irreparable. The
data does not include wells/pumps installed by households and GPs through their own
funds; however the number of such installations is relatively low.
18
STATUS OF WATER SUPPLY INSTALLATIONS IN MP
Hand pumps
Description
Nos.
%
Spot source
Nos.
Piped water supply
Nos.
%
%
3,589
Total installations
2,83,651
2,321
In working condition
2,42,034 85
1,839
79
2,924
81
Temporarily non functioning due to
6,296
2
180
8
208
6
35,321
13
302
13
457
13
drying of water sources
Irreparable
100
100
100
Source: PHED, 2001.
Although coverage is largely satisfactory in terms of physical installations, the reduced
availability of safe water is a cause for concern. There are three issues:
•
Over-exploitation of water sources, especially in west MP, where a number of
villages face the problem of drying up of water sources.
Water is not available
even at a depth of 800 feet in Neemuch district.
•
Preventive maintenance of hand pumps is practically non-existent.
Further,
inappropriate operational practices such as installing additional pipes results in a
collapse of the vertical column of the pipeline.
•
Average downtime for repairs when needed is 4-5 days and up to a month in
remote areas; a contributory factor being a shortage of hand pump mechanics with
PHED.
Sanitation facilities and coverage
Sanitation in the rural context is perceived as physical provision of latrines,
Solid
waste management, effluent disposal and surface water drainage are considered to be
of even lower priority although some GPs have provided drains for effluent from
households.
Since 1992-93 PHED has been the nodal agency for implementing sanitation
programmes in MP.
According to PHED, 215,080 toilets have been constructed for
households below poverty line (BPL), whereas the corresponding figure for APL
households is 240,569.
These numbers do not include privately constructed septic
tank type latrines. Less than 8% of all rural households are estimated to have an IHL.
19
Sanitation is perceived primarily as the presence of a physical latrine (Delivery
Mechanisms for Water and Sanitation in MP, MSG, 2001):
•
The installed IHLs (purchased through a subsidy scheme) are typically used for
storage, bathing etc.
•
Attitudinal barriers: The community is used to the traditional practice of defecating
in the open and does not readily accept small latrines.
•
Low priority : Even in large crowded villages where there is a lack of open space,
sanitation is low priority; a TV typically takes precedence over an IHL.
•
Lack of water: Use of existing facilities is often reduced due to lack of water for
flushing/cleaning.
•
Low awareness levels: While communities have an appreciation of the link between
drinking safe water and health, awareness of the importance of hygiene practices is
low.
•
Technical issues: Key concerns include collapse of brick lining, lack of ventilation,
flooding of pits during rains, use of one pit model etc.
These experiences
adversely affect demand for latrines.
20
3. VISION, GOALS, OBJECTIVES AND ENVISAGED OUTCOMES
3.1
State’s Mission
The State’s vision statement is as follows:-
‘All people living in the state of Madhya Pradesh will have the knowledge and
skills required to keep themselves healthy, and have equity in access to effective
and affordable health care, as close to the family as possible, that enhances
their quality of life1, and enables them to lead a healthy productive life’.
Thus, it may be observed that the State’s vision has primarily two components, namely
empowering the people living in the State with knowledge and skills required to keep
them healthy and equity in access to effective and affordable health care.
The State of Madhya Pradesh also subscribes to the vision adopted by the National
Rural Health Mission. Consequently, the adapted vision components to be pursued by
the State are presented in the box below:
Equip people with knowledge and skills required to keep themselves healthy.
Provide effective healthcare to rural population throughout the State with special focus on
worst performing districts, which have weak public health indicators and/or weak
infrastructure. These districts will receive special focus. These are: Dindori, Damoh, Sidhi,
Badwani, Anuppur, Chhindwara, Rewa, Betul, Raisen, Seoni, Chhatarpur, Morena and
Sheopur.
Raise level of public spending on health from 0.89% GDP to 2-3% of GDP, with improved
arrangement for community financing and risk pooling.
Undertake architectural correction of the health system to enable it to effectively handle
increased allocations and promote policies that strengthen public health management and
service delivery in the State.
Revitalize local health traditions and mainstream AYUSH into the public health system.
Effective integration of health concerns through decentralized management at district, with
determinants of health like sanitation and hygiene, nutrition, safe drinking water, gender and
social concerns.
Address inter-district disparities.
Pursue time bound goals and publish report to the people of the state on progress.
Improve access to rural people, especially poor women and children to equitable, affordable,
accountable and effective primary health care.
Vision Statement of State Rural Health Mission, MP
1 Quality of life is the perceived physical and mental health of a person or group over
time
21
Goal of NRHM
3.2
The goal of National Rural Health Mission is to improve the availability of and access to
quality health care by the people especially for those residing in rural areas, the poor,
women and children. The main aim of National Rural Health Mission is to provide
accessible, affordable, accountable, effective and reliable primary health care,
especially to poor and vulnerable sections of the population. It aims at reduction in
Infant Mortality Rate and Maternal Mortality Ratio, universal access to public health
services such as women's health, child health, water, sanitation and hygiene,
immunization and nutrition, prevention and control of communicable and noncommunicable diseases including locally endemic diseases; access to integrated
comprehensive primary health care; population stabilization; gender and demographic
balance; revitalize local health traditions and mainstream AYUSH and promotion of
healthy lifestyle.
Objectives of State Programme Implementation Plan under NRHM
3.3
The State Programme Implementation Plan under the National Rural Health Mission
shall pursue the following objectives by the year 2012: •
Reduction in Infant Mortality Rate to 60 per 1000 live births
•
Maternal Mortality Ratio reduced to less than 220 per 1,00,000 live births
•
Total Fertility Rate is reduced to 2.1.
•
Morbidity and mortality due to common communicable diseases such as
malaria, dengue, leprosy, and tuberculosis is reduced as per the objectives set
in the National NRHM document.
•
At least 36% of Community Health Centres are upgraded to meet IPHS by
2008 and 100% by 2010.
•
170 Comprehensive Emergency Obstetric Care institutions are strengthened
and made functional, 40% by 2006, 55% by 2007, 75% by 2008 and 100 % by
2009 and 500 Basic Emergency obstetric Care institutions are strengthened
and 40% made functional by the year 2006, 50% by 2007, 60% by 2008, 80%
by 2009 and 100% by 2010.
•
40% of Accredited Social Health Activists (ASHA) are identified by 2006, 70%
by 2007 and 100% by 2008 and 40% trained by 2007, 80% by 2008 and 100%
by 2009.
•
The proportion of institutional deliveries is increased to 50% by year 2007, 65%
by year 2008 and 75% by year 2009.
22
I
•
Janani
Suraksha Yojana for below
poverty line families is effectively
implemented to improve institutional deliveries through provision of referral
transport, escort and improved hospital care to all BPL families by the year
2007.
•
To improve outreach of health services through Mobile Medical Units in difficult
to reach areas and disadvantaged population groups.
Envisaged Outcomes from the Mission in terms of Programme Indicators
3.4
•
IMR reduced to 60/1000 live births by 2012.
•
Maternal Mortality reduced to below 220/100,000 live births by 2012.
•
TFR reduced to 2.1 by 2012.
•
Malaria Mortality Reduction Rate - 50% up to 2010, additional 10% by 2012.
•
Filaria/Microfilaria Reduction Rate - 70% by 2010, 80% by 2012 and elimination
by 2015.
•
Dengue Mortality Reduction Rate - 50% by 2010 and sustaining at that level
until 2012.
•
Cataract operations-increasing to 46 lakhs until 2012.
•
Leprosy Prevalence Rate -reduce from 1.8 per 10,000 in 2005 to less that 1
per 10,000 thereafter.
•
Tuberculosis DOTS series - maintain 85% cure rate through entire Mission
Period and also sustain planned case detection rate.
•
Upgrading all Community Health Centers to Indian Public Health Standards.
•
Increase utilization of First Referral units from bed occupancy by referred cases
of less than 20% to over 75%.
•
Engaging 43913 female Accredited Social Health Activists (ASHAs).
The expected outcomes at Community level
3.5
•
Availability of trained community level worker at village level, with a drug kit for
generic ailments.
•
Health Day observed at Aanganwadi level on a fixed day/month for provision of
immunization, ante/post natal check ups and services related to mother and
child health care, including nutrition.
•
Availability of generic drugs for common ailments at sub Centre and hospital
level.
•
Access to
appropriate and
guaranteed
hospital care through
assured
availability of doctors, drugs and quality services at PHC/CHC level and
23
assured referral-transport-communication systems to reach these facilities in
time.
•
Improved access to universal immunization through induction of Auto Disabled
Syringes, alternate vaccine delivery and improved mobilization services under
the programme.
•
Improved facilities for institutional deliveries through provision of referral
transport, escort and improved hospital care subsidized under the Janani
Suraksha Yojana (JSY) for the below poverty line pregnant women.
•
Availability of assured health care at reduced financial risk through pilots of
Community Health Insurance under the Mission.
•
Availability of safe drinking water.
•
Adoption of household toilets.
•
Improved outreach services to medically under-served remote areas through
mobile medical units.
•
Increased awareness about preventive health including nutrition.
The core strategies of the Mission
3.6
•
Capacity building of Panchayati Raj Institutions (PRIs) to recognize their stakes
in the public health system.
•
Promote access to improved healthcare at household level through the female
health activist (ASHA).
•
Promote formulation of Village Health Plans for each village through Village
Health & Sanitation Committees of the Gram Sabhas.
•
Strengthening sub-centre through better human resource development, clear
quality standards, better community support and an untied fund to enable local
planning and action and more ANMs.
•
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.
•
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).
24
•
Preparation and implementation of an inter-sector District Health Plan prepared
by the District Health Mission, including drinking water, sanitation, hygiene and
nutrition.
•
Integrating the management of vertical Health and Family Welfare programmes
at district level.
•
Provisioning of technical support to State and District Health Missions for
improved 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 involvement of private and corporate non-profit sector particularly in
underserved areas.
3.7
Supplementary Strategies
•
Regulation for private sector including the informal Rural Medical Practitioners
(RMP) to ensure availability of quality service to citizens at reasonable cost.
•
Promotion of public-private partnerships (PPP) for achieving public health
goals.
•
Mainstreaming AYUSH - revitalizing local health traditions.
•
Reorienting
medical education to support rural health
issues including
regulation of medical care and medical ethics.
•
Effective and visible risk pooling and social health insurance to provide health
security to the poor by ensuring accessible, affordable, accountable and good
quality hospital care.
3.8
The Special Focus Districts
While the Mission is state-wide, 10 districts having very poor indicators, low
population density and weak infrastructure shall receive special attention.
These districts are Dindori, Damoh, Sidhi, Badwani, Anuppur, Chhindwara,
Rewa, Betul, Raisen, Seoni, Chhatarpur, Morena and Sheopur.
While all
the Mission activities are the same for all the districts, the high focus districts
would be more closely monitored by the State apart from providing them with
increased technical assistance in implementing the respective district PIPs.
25
The efforts so far
3.9
The emphasis in the first six months since the launch of the mission has been
on the preparatory activities necessary for the laying the ground work for
implementation of the Mission such as:
Institutional Framework
•
The State and district level societies have been merged. State and District
Missions have been set up. The institutional framework including Executive
Committee at the State level has been put in place.
•
State has organized the launch workshop.
•
Mission Document; Guidelines on Indian Public Health Standards; Guidelines
for ASHA; Training Modules for ASHA; Guidelines for District Health Mission
and merger of societies have been disseminated to the districts.
•
Moll has been signed with Gol. It spells out the reform commitment of the State
in terms of its enhanced public spending on health, full staffing of management
structures, steps for decentralization and promotion of district level planning
and implementation of various activities and achievement of milestones.
Programmes
•
Reproductive and Child Health Programme - II (RCH-II), the Janani Suraksha
Yojana (JSY), Prasav Hetu Parivahan Yojna (PHPY) and Vijaya Raje Janani
Kalyan Beema Yojna have been launched.
•
Operationalisation of CEmONC facilities is being stepped up under the EC-
supported Sector Investment Programme, which is in its last leg this year.
•
Polio eradication programme has been intensified.
•
Sterilization insurance scheme has been introduced.
•
Routine Immunization programme is being strengthened through alternative
vaccine delivery system and Auto Disabled Syringes have been introduced.
•
State’s RCH II Programme Implementation Plan RCH II has been appraised by
the National Programme Coordination Committee of the Gol.
Infrastructure
•
Facilities have been identified for detailed survey.
•
Repair and renovation of Sub Centres taken up under RCH- II.
26
•
Untied fund of Rs. 10,000 provided to 8835 SHCs in the Joint accounts in the
names of Sarpanch and ANM.
•
2 CHCs in each district for upgradation to IPHS have been selected.
•
Upgradation of CHCs as Comprehensive Emergency Obstetric and Neonatal
Care (CEmONC) and Primary Health Centres for Basic Emergency Obstetric
and Neonatal Care (BEmONC) for 24 hours and 7 days a week delivery
services have been taken up.
•
Funds for upgradation of two CHCs per district to IPH Standards have been
released.
District Plans
•
Integrated district health action plans have been developed and appraised for
all the 48 districts. The appraisal has been done by the State Appraisal
Committees.
•
ASHAs selection for the year 2006 has been completed. Selection for the year
2007 is in progress.
•
Training of the state/district level trainers of ASHAs completed. District level
training has been initiated.
Technical Support to the Mission
•
State
Programme
Management
Unit
(SPMU)
and
District
Programme
Management Units established. These bodies will get subsumed in to the State
Health Systems Resource Center (SHSRC).
Training and Capacity Building
1.
Integrated training calendar prepared.
2. Training modules for Skilled Birth Attendants finalized.
3. Training of medical and para medical staff in BEmONC and CEmONC initiated.
4.
Public health management courses started. First two batches completed.
27
4. CRITICAL AREAS FOR CONCERTED ACTION
4.1 The launch of NRHM has provided the Central and the State Governments with a
unique opportunity for carrying out necessary reforms in the health sector. The
reforms are necessary for restructuring the health delivery system as well as for
developing
better
financing
health
mechanisms.
The
strengthening
and
effectiveness of health institutions like SHCs/PHCs/CHCs/CHs/district hospitals
should necessarily lead to positive consequences for the health programmes like
TB, Malaria, HIV/AIDS, Filaria, Family Welfare, Leprosy, Disease Surveillance etc.
as all programmes are based on the assumption that a functioning public health
system actually exists. In order to improve the health outcomes, it is necessary to
give close attention to critical areas like institutional mechanism, service delivery,
finances
(including
risk
pooling),
resources
(human,
physical,
knowledge
technology) and leadership. The following are identified as some of the areas for
concerted action:-
•
Well functioning and responsive health system;
•
Quality and accountability in the delivery of health services;
•
Need to acknowledge the rights perspective in respect of the poor and
vulnerable sections of the society and their empowerment;
4.2
•
Prepare for health transition with appropriate health financing;
•
Effective public private partnership for expanding choice and access;
•
Intra- and inter-sector convergence for effectiveness and efficiency.
•
Responsive health system meeting people’s health needs.
The Priorities and constraints
The table given below brings out an analysis of the priorities and constraints in
addressing the concerns:
S.
No.
Priorities
Constraints
1.
facilities
Functional
Operationalizing
Sub
Health Centers / PHCs /
CHCs / CHs / District
Hospitals
physical
or
absent
• Dilapidated
infrastructure.
• Non-availability of doctors / paramedics.
• Vacancies / absenteeism
• Lack of skills and skills mismatch
• Shortage of drugs, vaccine and supplies.
• Lack
of equipments,
non-functioning
equipments.
• Choked fund flows
28
S.
Priorities
Constraints
No.
2.
Ensuring
requisite
availability of skilled human
resources
3.
Accountability
system
4.
Empowerment for effective
decentralization
and
flexibility for location action
5.
Reducing
maternal and
child deaths and population
stabilization
6.
Action for preventive and
promotive health
7.
Disease Surveillance
of
health
• Lack of accountability framework.
• Inflexible financial resources.
• Facility specific service packages are not
defined__________________
• Large jurisdiction and poor monitoring.
• Lack of any plan for career advancement or
for systematic skill upgradation.
• Lack of articulation HR policies.__________
• Panchayati Raj institutions / ULBs / user
have little say in health system.
• Lack of decentralization. ________________
• Only tied funds.
• Local initiatives have no role.
• Centralized management and schematic
inflexibility.
• Lack
of
mandated
functions
of
PRIs/ULBs/users.
• Lack of financial and human resources for
local action.
• Lack of indicators and local health status
assessments that can contribute to local
planning.
• Poor capability to design and plan
programmes.
• Lack of 24X7 facilities for safe deliveries.
• Lack of facilities with emergency obstetric
care.
• Unsatisfactory access and utilization of
skilled assistance at birth.
• Lack of equity / sensitivity in family welfare
services / counseling.
• Non-availability
of
for
Specialists
anesthesia, obstetric care, pediatric care,
etc.
• No system of new born care with adequate
referral support.
• Lack of referral systems.
• Gender inequity adversely influencing
utilization of health services.
• Socio-cultural
practices
and
taboos
affecting health-seeking behavior.
• No action on promoting healthy lifestyles
whether it be fighting alcoholism or
promoting tobacco control or promoting
positive actions like sports / yoga etc.
• Week school health programmes.
• Absence of health counseling / early
detection.
• Compartmentalized IEC of every scheme.
• Vertical programmes for communicable
diseases.
29
S.
No.
8.
9.
Priorities
Health
Management
Information System._______
Planning and monitoring
with community ownership
12.
Work towards women's
empowerment and securing
entitlements of SCs / STs /
OBCs / Minorities______ __
Convergence
of
programme for combating /
preventing HIV / AIDS,
chronic
diseases,
malnutrition, providing safe
drinking water etc. with
community support._______
Chronic disease burden
13.
Social security to poor
10.
11.
Constraints
• No integrated / coordinated action for
disease surveillance at various levels in
place yet.
district
level
• Lack
of
block
and
epidemiological date.
• Poorly designed and poorly administered
system.______________________________
• Lack of involvement of local community,
PRIs, RKSs, NGOs in monitoring public
health institutions like SHC / PHC / CHC /
CH / District Hospitals._____
• Insensitivity
and
neglect of service
socio-economic
providers
with
other
barriers for accessing public health
services.______________
• Vertical implementation of programme.
• Only curative care.
• Inadequate service delivery.
• Non-involvement of community.
• Lack of integration of programmes with
main health programmes.
• Poor IEC / advocacy.
• Inadequate Policy interventions.
• Large out of pocket expenditures even
while attending free public health facilities food / transport, escort, livelihood loss etc.
• Lack of financial security in the event of
catastrophic illness.
30
5. BROAD FRAMEWORK FOR IMPLEMENTATION
5.1 Based on the analysis of the priorities, constraints and the action to overcome
them, a broad framework of implementation of NRHM is proposed as follows:
State’s Leadership
The
State
has
determined
to
decentralize
planning
and
implementation
arrangements to ensure that need-based and community-owned District Health
Action Plans become the basis for interventions in the health sector. The State has
also taken steps to introduce innovative schemes to deal with local issues. The
State has taken steps to devolve requisite administrative and financial powers at
various administrative levels. The State is also seeking to increase its expenditure
on health sector by at least 10% every year over the Mission period. The State
would be guided by the mutually agreed milestones as are reflected in the MOD
signed with the Gol. The State would undertake rigorous capacity building
initiatives to ensure that integration of programme management bodies and the use
of untied funds is most effectively optimized so that complex health issues are
competently addressed.
Institutionalizing community led action for health
The State is committed to achieve the goals enshrined under the NRHM and MDG
keeping the community in focus. It is the stated agenda of the State that PRIs, right
from the village to district level, would have to be the central stakeholders of the
public health delivery system in their respective jurisdiction. Other vibrant
community organizations and women’s groups like SHGs will also be associated in
communitization of health care.
The NRHM would seek to involve the PRIs at each level i.e. Gram Panchayat,
Janpad Panchayat and Zila Panchayat and enhance their capacities for ensuring
community mobilization efforts for appropriate health seeking behaviour.
•
The Village Health and Sanitation Committee (VHSC) will be formed in each
village under each Gram Sabha ensuring adequate representation to the
disadvantaged categories like women, SC / ST / OBC /minority communities.
31
•
The Sub Health Centres shall function in close coordination with village health
and sanitation committees as well as the village development committee at the
Gram Panchayat level.
•
Similarly, the Primary Health Centres and Community Health Centres will also
work in close conjunction with Janpad Panchayats.
•
The RKSs will undertake the day-to-day management of PHCs and CHCs and
the capacities of these RKSs will be suitably enhanced.
•
The District Hospital and the Civil Hospital would be accountable to District
Health Society and their Rogi Kalyan Samitis will undertake their day-to-day
management functions. The capacity of RKSs of district and civil hospitals will
also be suitably enhanced.
To institutionalize community led actions for health; the village health and sanitation
committees will be constituted in each village in a phased manner. These
committees will prepare village health action plans. These village action plans will
be synthesized at Gram Panchayat and Janpad Panchayat levels before being
refined into integrated district health action plans. Each village health and sanitation
committee will be provided untied fund of Rs. 10000/- per year for initiating and
implementing local health actions based upon its approved village health action
plans.
Promoting Equity
This is one of the main challenges under NRHM.
vulnerable
through
education
and
health
Empowering those who are
education,
giving
priority
to
areas/hamlets/households inhabited by them, running fully functional facilities,
exemption for below poverty line families from all charges, ensuring access, risk
pooling, human resource development / capacity building, recruiting volunteers
from amongst them are important strategies under the Mission.
These are
reflected in the planning process at every level. Under the NRHM, The State would
make conscious efforts to address the issue of inequity.
The percentage of
vulnerable sections of society using the public health facilities would be a
benchmark for the performance of these institutions.
Promoting Preventive Health
The NRHM would increase the range and depth of programmes on Health
Education / IEC activities which are an integral part of activities under the Mission
at every level. In addition it would work with the departments of education to make
32
health promotion and preventive health an integral part of general education. The
Mission would also interact with the Ministry of Labour for occupational health and
the Ministry of Women and Child Development to ensure due emphasis on
preventive and promotive health concerns.
Dealing with Chronic Diseases and Mental Health
Tobacco,
cancer,
diabetes and
renal diseases,
cardio vascular diseases,
neurological diseases and mental health problems and the disability that may arise
due to the chronic diseases are major challenges before the NRHM. Special
emphasis will be given on mental health programme so that specific psychiatric
health needs are adequately addressed. It may be mentioned here that by
addressing the mental health, the social health would also be automatically
addressed thereby fully meeting the premise of health definition as provided by
WHO. It is also proposed to integrate the disease surveillance and mobilize
preventive and curative care with the regular health care programmes at all levels.
Reducing child and maternal mortality rates and reducing fertility rates population stabilization through quality services
NRHM provides a thrust for reduction of child and maternal mortality and in
reduction of the fertility rates. The approach to population stabilization is to provide
quality heath services in remote rural areas along with a wide range of
contraceptive choices to meet the unmet demand for these services. Efforts are on
to provide quality reproductive health services (including delivery, safe abortions,
treatment of Reproductive Tract Infections and Family Planning Services to meet
unmet needs, while ensuring full reproductive choices to women). Also, it is the
strategy to promote male participation in Family Planning. Efforts would also be
made to suitably reorient the service providers at all levels to deal with the needs of
victims of domestic violence.
Reduction of IMR requires special and sustained attention in respect of integrated
management of neonatal and childhood illnesses (IMNCI). Keeping in view the
continued high proportion of domiciliary deliveries, special attention is required on
home based newborn care particularly in rural areas and in urban slums. In
addition, greater convergent action is called for in order to influence the wider
determinants of health care like female literacy, safe drinking water, sanitation,
gender and social empowerment, early childhood development, nutrition, marriage
after 18/21, spacing of children, and behavioral changes etc.
33
The main strategy for maternal mortality focuses on promotion of institutional
deliveries at health facilities both in the government as well as private sectors.
Efforts would also be made to concomitantly develop competencies needed for
Skilled Birth Attendants (SBAs) in the entire cadre of ANMs, LHVs and Staff
Nurses. Further essential obstetric care competency is required to be imbibed by
select medical officers posted at BEmONC and CEmONC institutions. Regular
training of select Medical Officers to administer anesthesia has also been taken up.
Also, multi skill training of Medical Officers, ANMs and Para-medics will be initiated
to bridge gaps in skills and performance. Intense IEC would be pursued to ensure
behavioral changes that relate to better child survival and women’s health i.e.
exclusive breast feeding, timely initiation of complementary feeding, young child
feeding, spacing, age at marriage, education of the girl child etc. CHCs are being
upgraded to CEmONC / BEmONC for providing referral services to the mother and
child and taking care of obstetric emergencies and complications for provision of
safe abortion services and for prevention, testing/counseling in respect of HIV
AIDS.
Adolescent health is another significant thematic area of attention under the
NRHM. Adolescent friendly health services will be provided in identified primary
health centres and community health centers to address the specific health needs
of adolescents for both in and out-of-school adolescents.
Management of NRHM activities at State / District / Sub district level
Block Level Pooling
The success of decentralization experiment would depend on the strength of the
pillars supporting the process. It is imperative that management capacities be built
at each level.
To attain the outcomes, the NRHM would provide management
costs up to 6% of the total annual plan approved for a State/district as has been
introduced under the RCH-II programme. Apart from medical and para-medical
staff, such services would include skills for financial management, improved
community
processes,
procurement and
logistics,
improved
collection
and
maintenance of data, the use of information technologies, management information
system and improved monitoring and evaluation etc. The NRHM would also
establish strong managerial capacity at the block level as blocks would be the link
between the villages and the districts.
At the district level the Mission would
support and insist on developing health management capacities and introducing
34
policies in a systematic manner so that over time all district programme officers and
their leadership are professionally qualified public health managers. Management
structures at all levels will be accountable to the Panchayati Raj institutions, the
State Level Health Mission and the National Level Missions/Steering Group.
The amount available under the management cost could also be used for
improving the work environment as such improvements directly lead to better
outcomes. The management structure holds the key to the success of any
programme and priority would be given to direct efforts to develop appropriate
arrangements for effective delivery of NRHM. Clarity of tasks, fund flows, powers,
functions, account keeping, audit, etc. will be attempted at all levels.
Based on the outcomes expected in NRHM, the organization structure of the health
department at different levels would be carefully reviewed. The State will constantly
undertake review of management structure and devolution of powers and functions
to carry out any mid course correction. Block Level Pooling will be one of the
priority activities under the NRHM. Keeping in view the time line needed to make
all facilities fully functional, specialists working in PHCs would be relocated at
CEmONCs to facilitate their early synchronization.
Outreach programmes are
being organized with “block pooled” CHCs as the nodal point. NRHM will attempt
to set up Block level managerial capacities as per need. Creation of a Block
Medical Officer’s office to support the supervision of NRHM activities in the Block
would be a priority. Support to block level CHCs will also aim at improving the
mobility and connectivity of health functionaries with support for Ambulances,
telephones, computers, electric connection, etc.
Human resources for rural areas
Improvement in the health outcomes in the rural areas is directly related to the
availability of the trained human resources. The Mission aims to increase the
availability through provision of trained women as ASHAs/Community Health
Workers (resident of the same village/hamlet for which they are appointed as
ASHA). The Mission also seeks to provide minimum two Auxiliary Nurse Mid-wives
(ANMs) against one at present at each Sub Health Centre (SHC) to be fully
supported by the Government of India. Similarly, against the availability of one staff
nurse at the PHC, it is proposed to provide three Staff Nurses to ensure round the
clock services in every PHC. The Outpatient services would be strengthened
through posting/ appointment on contract of AYUSH doctors over and above the
35
Medical Officers posted there. The State would integrate AYUSH by relocation at
PHC and/or by new contractual appointment. GOI support will be for all new
contractual posts and not for existing vacancies that State has to fill up.
The
Mission seeks to bring the CHCs on a par with the Indian Public Health Standards
(IPHS) to provide round the clock hospital-like services. As far as manpower is
concerned, it would be achieved through provision of seven Specialists as against
four at present and nine staff nurses in every CHC (against seven at present). A
separate AYUSH set up would be provided in each CHC/PHC. Contractual
appointment of AYUSH doctors will be provided for this purpose. This would be
reflected in the State Plans as per their needs.
Given the current problems of availability of both medical as well as paramedical
staff in the rural areas, the NRHM seeks to try a range of innovations and
experiments to improve the position. These include incentives for compulsory rural
posting of Doctors, a fair, transparent transfer policy, involvement of Medical
Colleges, improved career progression for Medical / Para Medical staff, skill
upgradation and multi-skilling of the existing Medical Officers, ANMs and other
Para Medical staff, strengthening of nursing / ANM training schools and colleges to
produce
more
paramedical
staff,
and
partnership with
non
governmental
stakeholders to widen the pool of institutions. The Ministry has already initiated the
process for the upgradation of ANMs into Skilled Birth Attendants (SBA) and for
providing six-month anesthesia course to the Medical Officers. Convergence of
various schemes under NRHM including the disease control programmes, the
RCH-II, NACO, disease surveillance programme, would also provide for optimum /
efficient utilization of all paramedical staff and help to bring down the operational
costs.
State level Resource Centres for capacity development
Decentralized Planning, preparation of district plans, community ownership of the
health delivery system and inter-sectoral convergence are the pillars on which the
super-structure of the NRHM would be built. The implementation teams particularly
at district and state levels would require development of specific skills. The State
Health Resource Centre (SHRC) will act as the complementary technical capacity
in the improved programme management and service delivery.
36
The NRHM would also require a comprehensive plan for training at all levels. The
States would closely review its training infrastructure and identify the investment
required so that effective HRD is put in place.
Drug supplies and logistics management
Timely supply of drugs of good quality which involves procurement as well as
logistics management is of critical importance in any health system. The GoMP
has recently issued its Drug Policy wherein the State plans to institute a system of
drug supplies and logistics management on the lines of Tamil Nadu.
The State
would also seek to build capacity so that it may effectively take up scale
procurement of goods and services.
Monitoring / Accountability Framework
The NRHM proposes an intensive accountability framework through a three
pronged process of community based monitoring, external surveys and stringent
internal monitoring. Facility and Household Survey, NFHS-II, RHS (2002) would act
as the baseline for the mission against which the progress would be measured.
While the process of communitization of the health institutions itself would bring in
accountability, the NRHM would help this process by wide dissemination of the
results of the surveys in a language and manner which could be understood by the
general population. It would be made compulsory for all the health institutions to
prominently display information regarding grants received, medicines and vaccines
in stock, services provided to the patients, user charges to be paid (if any) etc, as
envisaged in the Right to Information Act. The community as well as the Rogi
Kalyan Samitis would be expected to monitor the performance of the health
facilities on those parameters. Health Monitoring and Planning Committees would
be formed at PHC, Block, District and State levels to ensure regular community
based monitoring of activities at respective levels, along with facilitating relevant
inputs for planning. Organization of periodic Public Hearings or dialogues would
strengthen the direct accountability of the Health system to the community and
beneficiaries.
The State Health Society/Mission will also monitor progress
periodically. Both at State and district levels, Public Reports on Health would be
published to report to the community at large on progress made. The State would
involve NGOs, resource institutions and local communities in developing this
monitoring arrangement. The Mentoring Group on ASHA, the National Advisory
Committee on Community Action (which have been constituted with the leading
37
NGOs as their members) and the Regional Resource Centres would provide
valuable inputs to the Mission. A wide network of MNGOs, FNGOs / SNGOs would
also be providing feedback to the Mission.
The periodic external, household and facility surveys would track the effectiveness
of the various activities under the NRHM for providing quality health services.
The requirements of audit will apply to all NRHM activities. The State and District
Health Missions will be subject to annual audit by the CAG as well as by a
Chartered Accountant and any special audit that the Gol may specify. Special audit
by agencies like the Indian Public Auditors of India could also be undertaken. All
procedures
of government
regarding
financial
grants
including
Utilization
Certificates etc. would apply to the State and District Health Societies.
For the accountability framework to be truly community-owned, the effort will be to
ensure that at least 70 percent of the total NRHM expenditures are made by
institutions and organizations that are being supervised by an institutional
PRI/community group.
Monitoring outcomes of the Mission
•
Right to health is recognized as inalienable right of all citizens as brought out by
the relevant rulings of the Supreme Court as well as the International
Conventions to which India is a signatory. As rights convey entitlement to the
citizens, these rights are to be incorporated in the monitoring framework of the
Mission.
Therefore, providing basic Health services to all the citizens as
guaranteed entitlements will be attempted under the NRHM.
•
The village health records would be maintained and updated by village health
and
sanitation
committees.
These
records would
form
the
basis for
development and the implementation of respective village health plans.
•
Periodic Health Facility Survey at SHC, PHC, CHC, District level to see if
service guarantees are being honored. [By district /Block level Mission Teams/
research and resource institutions].
•
Formation of Health Monitoring and Planning Committees at PHC, Block,
District and State levels to ensure regular monitoring of activities at respective
levels, along with facilitating relevant inputs for planning.
•
Sharing of all data and discussion at habitation/ village level to ensure full
transparency.
38
•
Display of agreed service guarantees at health facilities, details of human and
financial resources available to the facility.
•
Sample
household
and
facility
surveys
by
external
research
organizations/NGOs.
•
Public reporting of household and health facility findings and its wider
dissemination through public hearings and formal reporting.
Convergence within the Health Department
Special programmes have been initiated as per need for diseases like TB, Malaria,
Filaria, HIV AIDS etc.
While the disease specific focus has helped in providing
concerted attention to the issue, the weak or absence of integration with other
health programmes has often led to lack of coordination and convergent action. All
central programmes have worked on the assumption that there is a credible and
functional public health system at all levels in all parts of the country. In practice,
however, the public health system has not been in a satisfactory state. The
challenge of NRHM, therefore, is to strengthen the public health institutions like
SHC/PHC/CHC/Sub Divisional and District Hospitals. This will have positive
consequences for all health programmes. Whether it is HIV/AIDS, TB, Malaria or
any other disease, NRHM attempts to bring all of them within the umbrella of a
Village/District/State Health Plan so that preventive, promotive and curative
aspects are well integrated at all levels. The intention of convergence within the
Health Department is also to reorganize human resources in a more effective and
efficient way under the umbrella of the common District Health Society. Such
integration within the Health Department would make available more human
resources with the same financial allocations. It would also promote more effective
interventions for health care.
The pandemic of HIV/AIDS requires convergent action within the health system. By
involving health facilities in the programme at all stages, it is likely to help early
detection, effective surveillance and timely intervention wherever required. The
NACO has presence only from district level upwards. The NRHM would enable the
NACO to provide necessary investment and support to the programme at district
and sub district levels. NACO will provide Counselors at CHCs and PHCs along
with testing kits as part of the NACP-III. It would also help to integrate training on
HIV/AIDS to ASHA, ANMs, LHVs, para-medicals, lab technicians and medical
officers. Common programmes for condom promotion and I EC are also planned.
NRHM seeks to improve outreach of health services for common people through
39
convergent action involving all health sector interventions.
The RTI / STI
management services will be strengthened at PHCs by ensuring availability of
testing and counseling services on identified PHCs and appropriate behaviour
change communication interventions for adoption of healthy practices and life
styles.
Convergence with other departments
The indicators of health depend as much on drinking water, female literacy,
nutrition, early childhood development, sanitation, women’s empowerment etc. as
they do on hospitals and functional health systems.
Realizing the importance of
wider determinants of health, NRHM seeks to adopt a convergent approach for
intervention under the umbrella of the district plan. The Anganwadi Centre under
the ICDS at the village level will be the principal hub for health action. Likewise,
wherever village committees have been effectively constituted for drinking water,
sanitation, ICDS etc. NRHM will attempt to move towards one common Village
Health Committee covering all these activities. Panchayati Raj institutions will be
fully involved in this convergent approach so that the gains of integrated action can
be reflected in District Plans. While substantial spending in each of these sectors
will be by the concerned Department, the Village Health Plan/District Plan will
provide an opportunity for some catalytic resources for convergent action. NRHM
household surveys through ASHA, AWW will target availability of drinking water,
firewood, livelihood, sanitation and other issues in order to allow a framework for
effective convergent action in the Village Health Plans.
The success of convergent action would depend on the quality of the district
planning process. In MP, the District Health Action Plans reflect integrated action
in all section that determine good health - drinking water, sanitation, women’s
empowerment,
adolescent
health,
education,
female
development, nutrition, gender and social equality.
literacy,
early
child
At the time of appraisal of
District Health Plan, care would be taken to ensure that the entire range of wider
determinants of health have been taken care of in the approach to convergent
action.
Role of Non Governmental Organizations
The Non-governmental Organizations are critical for the success of NRHM. With
the mother NGO programme scheme, 24 MNGOs covering 37 districts have
40
already been appointed. Their services are being utilized under the RCH-II
programme. The Disease Control programmes, the RCH-II, the immunization and
pulse polio programme, the JSY make use of partnerships of variety of NGOs.
Efforts are being made to involve NGOs at all levels of the health delivery system.
Besides advocacy, NGOs would be involved in building capacity at all levels,
monitoring and evaluation of the health sector, delivery of health services,
developing innovative approaches to health care delivery for marginalized sections
or in
underserved
areas and
aspects,
working together with
community
organizations and Panchayati Raj institutions, and contributing to monitoring the
right to health care and service guarantees from the public health institutions. The
effort will be to support/ facilitate action by NGO networks of NGOs in the State
which would contribute to the sustainability of innovations and community
participation in the NRHM.
Grants-in-aid systems for NGOs will be established at the District and State levels
to ensure their full participation in the Mission.
Risk pooling and the poor
While setting up of effective health insurance system is clearly a very important
mission goal, it is realized that the introduction of such a system without the back
up of a strong preventive health system and curative public health infrastructure
would not be cost effective. Such a venture would only end up subsidizing private
hospitals and lead to escalation of demand for high cost curative health care. The
first priority of the Mission is therefore to put the enabling public health
infrastructure in place.
While the public and private insurance companies would be encouraged to bring in
innovative insurance products, the Mission would strive to set up a risk pooling
system where the State and the local community would be partners. This could be
done by resource sharing, facility mapping, setting standards, establishing standard
treatment protocols and
costs, and
accreditation
of facilities in the non
governmental sector.
Primary health care would be made accessible to all. However, in the case of need
for hospitalization, CHCs would be the first referral unit. Only when the CHC is not
in a position to provide specialized treatment, a patient would be referred to an
accredited private facility/teaching hospital. The BPL patients would have the
choice of selecting any provider out of the list of accredited hospitals as provided
41
under various schemes of GoMP. Reimbursement for the services would be made
to the hospitals based on the standard costs for various interventions decided by
the experts from time to time.
It is envisaged that the hospital care system would progressively move towards a
fully funded universal social health insurance scheme. Under such a system, the
government facilities would also be expected to earn their entire requirement of
recurring expenditure including the salary support out of the procedures they
perform, while taking care that access to those who cannot pay is not
compromised. This system would obviously work only when the personnel working
in the CHCs are not part of a state cadre but are recruited locally at the district level
by the District Health Mission on contract basis. Since evolving such a system is
likely to take some time, it is proposed that the RKSs take greater charge of day-to-
day management of the health institutions for improving the quality of care.
Reforms in Medical / Nursing Education
The medical / para medical education system would require a new orientation to
achieve these objectives. While the existing colleges would require strengthening
for increased seat capacity, a conscious policy decision would be required to
promote new colleges in deficient states. A fresh look also needs to be given on the
norms for setting up new medical colleges under the regulations framed under
Indian Medical Council Act to see whether any relaxation is necessary for such
areas. The viability of using the caseload at district hospital for setting up Govt. /
private medical colleges would also be examined. Apart from creating teaching
infrastructure at the district level, it would also promote much needed investment
and improvement in tertiary care in the district hospitals.
The curriculum in the Medical Colleges perhaps gives undue emphasis on
specialization and tertiary care which is available only in large cities. In the
syllabus, the primary health care as well as preventive aspects of health are largely
ignored.
It is therefore natural for the students to aspire for a career in a big
hospital in urban setting. In the process the health care in the rural areas suffers.
The Mission would look at ways and means to correct the situation.
The NRHM also recognizes the need for equipping medical colleges and other
suitable tertiary care centres - including select district hospitals, select not for profit
hospitals and public sector undertaking run hospitals for a variety of special
42
courses to train medical officers in short term courses to handle a large number of
essential specialist functions in those states where medical colleges and
postgraduate courses are below recommended norms. This includes courses from
multi skilling serving Medical Officers, especially for anesthesia, emergency
obstetrics, emergency pediatrics especially new born care, safe MTP services,
mental health, eye care, trauma care etc.
Further short-term programmes are
needed to upgrade skills of nurses and ANMs to that of nurse-practitioners for
those centres/regions which potentially have adequate nurses, but a chronic
shortage of doctors over at least two decades.
The Mission would continue to support strengthening of Nursing Colleges wherever
required, as the demand for ANMs and Staff Nurses and their development is likely
to increase significantly. This would be done on the basis of need assessment,
identification of possible partners for building capacities in the governmental and
non governmental sectors in each of the States/UTs, and ways of financing such
support in a sustainable way. Special attention would be given to setting up ANM
training centres in tribal blocks which are currently para-medically underserved by
linking up with higher secondary schools and existing nursing institutions.
Efforts to improve skills of Registered Medical Practitioners would also be
introduced.
The NRHM recognizes the need for universal continuing medical
education programmes, which are flexible and non-threatening to the medical
community, but which ensures that they keep abreast of medical advances, and
have access to unbiased medical knowledge, and adequate opportunity to refresh
and continuously upgrade existing knowledge and skills.
Pro-people partnerships with the non-governmental sector
The Non-governmental sector accounts for nearly 4/5 of health expenditure in
India. In the absence of an effective Public Health System, many households seek
health care from the Non-governmental / organized private sector also. A variety of
partnership modes are proposed to be undertaken by the State.
Public Private Partnerships would be evolved, modeled and operationalized with
the objective of expanding the service base so that access to under-served and
under-reach population may be ensured. A system of accreditation would be
evolved to ensure quality and service responsiveness amongst these partnerships.
43
The other model pertains to working in close collaboration with professional bodies
such IMA, FOGSI, IAP and IPHA. The idea behind this partnership is to focus the
development and sustenance of best practices and observance of standard
treatment protocols. These bodies would also be involved in capacity building of
service providers both in public and private sectors.
The third model of partnership pertains to deriving coordinated technical assistance
from
development partners with a view to
refining
programme planning,
implementation, monitoring and evaluation of various programme interventions as
envisaged under NRHM. Further, representatives of these development partners
would also be the members of various committees / bodies so that the decision
making functions may be appropriately facilitated.
44
6. CORE STRATEGIES AND PROGRAMME IMPLEMENTATION PLAN
1.
Selection and Training of ASHA
The NRHM envisages that every village/large habitat will have a female
Accredited Social Health Activist (ASHA) chosen by and accountable to the
Panchayat to act as the interface between the community and the public health
system. The States have been given freedom to determine state-specific model
in operationalizing this bridge between the ANM and the village community
through the Panchayat.
Functioning as an honorary and a volunteer worker, she would be granted a
performance-based
compensation
for promoting
universal
immunization,
referral transport and escort services under RCH II, construction of household
toilets and other healthcare delivery programmes.
At the national level, Standing Mentoring Group supports the design of training
of these ASHA workers. The emphasis of this training is on best practices in
public health that are to be steered through the network of community-based
health resource organizations.
The ASHA workers would play a central role in facilitating the development of
Village Health Plan, working in close conjunction with the Anganwadi Workers
(AWWs), ANM, local level functionaries of other departments and in particular
the Self-Help Groups towards centrestaging the health agenda for the health
committee of the Gram Panchayat and, in reference to the State of Madhya
Pradesh, she would be the catalyzing resource for the Development Committee
of the Gram Sabha.
The Gol will bear the cost of training, incentives and the drug kits and the
remaining activities would be covered under the financial envelope given to the
States by the Gol. The drug kit will include generic medicines under allopathic
and AYUSH for treating common ailments.
The following activities constitute the Programme Implementation Plan for this
component:
45
■
Development and issuance of guidelines for selection and appointment of
ASHA workers and determination of district-wise number of required ASHA
Workers.
Identification of ASHA Workers.
District level orientation workshops for BMOs, Facilitators, PRIs and NGOs.
Identification of ASHA Workers through the Facilitators.
Training of State Level master trainers
Training of District Level master trainers
Training of Block level master Trainers
Training of ASHA Workers
Supply of drug kits for treatment of common ailments
Performance based incentive for ASHA Workers
Establishment of work routines for ASHA workers
Out of the total 43913 ASHAs in the State, 40 percent ASHA workers will be
selected in the year 2006, 70% by 2007 and 100% by 2008. The training of
40% ASHAs will be completed by the year 2007, 80% by year 2008 and 100%
by year 2009. It is proposed that their selection would be facilitated through 10
Facilitators in each of the 313 blocks. The process of facilitation would be
supported by 10 accredited mother NGOs through the active involvement of
Gram Panchayats and Gram Sabhas. The guidelines have been issued vide a
government order and the process of identification and selection of ASHA
Workers has been initiated.
2.
Village Health and Sanitation Committee constituted in all 52143 inhabited
villages and untied grants provided to them
Under this activity, Gram Sabhas shall be called upon to constitute Village
Health & Sanitation Committees. These committees shall steer the preparation
of Village Health & Sanitation Plans.
Each village and community participating in a Village Health Plan initiative
needs to establish a committee at the local level. Such committees are
essential for broad approaches to health improvement that involve a wide range
of activities and individuals. A committee can coordinate and support the
different activities, provide leadership for the community and can serve as the
community contact point with local and district government functionaries under
the NRHM programme. These committees can also facilitate broad community
46
participation in the programme, something that may be difficult to achieve by
outsiders. Local committees are therefore crucial for promoting the village
health approach in a community.
The composition of a local committee is crucial for a successful outcome.
Committee members should be such people who are respected, are able to
represent the interests of all sections of the community. It is also helpful if
ANM/MPW/ASHA/Anganwadi
Workers
and
such
local
staff
from
the
development department of the government are also included as members of
the committee.
The committee should be accountable and transparent both to the community
and to local government or NGOs that may provide support. The committee
should take minutes of all meetings, record the decisions made and make sure
that the community members have access to this information. A regular
feedback mechanism to the Gram Sabha should also be established, along
with a broader debate by the community about major activities and issues.
Since the committee would be managing untied funds, accounts will need to be
kept and made available to other community members and external support
agencies. To do this, the committee should elect executive officers, such as a
chairperson, treasurer and secretary, and meet regularly.
Some of these committee members may also be on the committees at Sub
Health Centre/PHC/CHC levels. Both in individual capacities as well as through
the Village Health & Sanitation Committees, these community representatives
shall have an interface with the field functionaries of government and receive
technical support and guidance from them. Essentially, the primary roles of the
Village Health & Sanitation Committees may be summarized as follows:
>
Disseminate, encourage and empower the community with regard to
knowledge and skills required to keep it healthy by addressing its health
seeking behavior outcomes.
>
Generate community demand for health care services.
>
Act as social monitors on quality and appropriateness of health care
services.
There are 52143 inhabited villages in the State. It is proposed to gradually build
up this village level institution, beginning with a sample coverage of 3% (1565
47
villages) by year 2007 and thereafter increasing to 25% (13035 villages) by
year 2008, 50% (26071 villages) by year 2010 and 100% (52143 villages) by
year 2012.
The activities to the run up to the operationalisation of Village Health &
Sanitation Committees would include the following stages:
■
Development of guidelines
■
Orientation of district, block and Janpad Panchayats and corresponding
government functionaries from the departments of health, women & child
development,
public
health
engineering
and
Panchayats
and
rural
development.
■
Identifying and orienting facilitators for organizing and leading village level
consultative processes.
■
Election of members to the Village Health & Sanitation Committees
■
Development of Village Health & Sanitation Plans by the Village Health &
Sanitation Committees.
■
Approval of Village Health & Sanitation Plans by respective Gram Sabhas.
■
Implementation and monitoring of village plans.
These village health and sanitation committees would be provided with an
untied grant of Rs. 10,000/- per year which would be used for developing the
village health plans and carrying-out the approved activities therein.
3.
Strengthening of Sub Health Centers
National Rural Health Mission proposes to provide to each Sub Health Center a
sum of Rs. 10,000/- as an untied fund to facilitate meeting urgent yet discreet
activities that need relatively small sums of money. For this purpose a fund will
be kept in a joint bank account of ANM and Sarpanch. This fund will be utilized
and spent on the activities approved by Village Health Committee and
administered by Auxiliary Nurse Midwife. In areas where the Sub Health Center
is not coterminous with Gram Panchayat and Sub Health Center covers more
than one Gram Panchayat, the Village Health Committee of the Gram
Panchayat where the Sub Health Center is located will approve the action plan.
However, the funds can be used for any of the villages, which are covered by
the Sub Health Center. The untied funds could be used only for the commonly
good and not individual needs except in case of referral and transport of
emergency situations. The untied funds could be used for undertaking local
48
health activity as envisaged under the village health plan. The indicative
purposes for which this fund could be used by the village health and sanitation
committee would include but be not limited to the following:-
•
Ad hoc payments for cleaning up Sub Health Center, especially after
childbirth.
•
Transport of emergencies to appropriate referral centers.
•
Transport of samples during epidemics.
•
Purchase of consumables such as bandages in Sub Health Center.
•
Purchase of bleaching powder and disinfectants for use in common areas of
the village.
•
Labour and supplies for environmental sanitation, such as clearing or
larvicidal measures for stagnant water.
•
Payment / reward to ASHA for certain identified activities.
According to the NRHM guidelines it is clear that the untied funds cannot be
used for payment of salaries, purchase of vehicle, to meet any recurring
expenditure or to meet the expenses of Gram Panchayat.
The state of Madhya Pradesh has 8835 Sub Health Centers. A sum of Rs.
10,000/- will be allocated per Sub Health Centre in the district plan of each
district. The CMHO of the district will be advised to transfer this fund to the
ANMs with the instructions that this fund will be kept in a joint account of ANM
and Sarpanch and will be administered and utilized by the ANM for the
activities approved by Village Health Committee. The guidelines will include the
directions for keeping the record and replenishment of this fund.
Likewise, every SHC will also get maintenance grant of Rs. 10,000/- per year for
undertaking infrastructure related need based maintenance.
The State has also decided to bring about communication connectivity with
SHCs and accordingly telephones will be installed at each SHC. The telephone
connections will be installed in 8835 SHCs during year 1 to year 3 and 1658
connections in year 4.
49
Out of the total 8835 SHCs in the State, 3253 SHCs are functioning from rented
premises. In addition, as per 2001 population there is a shortfall of 1658 SHCs.
Thus in all 4911 SHC buildings are required to be constructed during the
NRHM programme period. The State proposes to construct 200 SHCs in year
1, 1000 SHCs in year 2 and 3711 SHCs in year 3 as per the latest guidelines of
Gol.
As provided under NRHM guidelines, services of second ANM would be made
available at each SHC by appointing additional ANM on contractual basis. This
would ensure that the SHC will always be open for serving the clients. It is
proposed that during year 1,600 ANMs will be appointed, 1600 in year 2, 2000
in year 3, 3000 in year 4 and 3293 in year 5.
4.
Strengthening of PHCs
Every PHC will get an untied grant of Rs.25,000/- for undertaking planned local
health activity. Likewise each PHC will receive annual maintenance grant of
Rs. 50,000/- as provided under NRHM guidelines of the Gol.
There is a shortfall of 450 PHCs as per 2001 population. These PHCs will be
constructed during the NRHM programme period. It is proposed to construct
100 PHCs in year 2, 150 PHCs in year 3 and 200 PHCs in year 4.
5.
Strengthening of CHCs
Every CHC will get an untied grant of Rs.50,000/- for undertaking planned local
health activity. Likewise each CHC will receive annual maintenance grant of Rs.
1,00,000/- per year as provided under NRHM guidelines of the Gol.
There is a shortfall of 120 CHCs as per 2001 population. These CHCs will be
constructed during the programme period. It is proposed that construction of 60
CHCs will be undertaken in year 2 and year 3 respectively.
The State has also identified two CHCs per district for up-gradation to meet
IPHS criteria. The remaining CHCs will be upgraded to meet IPHS in phased
manner during the NRHM programme period.
Strengthening existing PHCs and CHCs, and provision of 30-50 bedded CHC
per one lakh population for improved curative care to a normative standard,
50
Indian Public Health Standards (IPHS) which defines personnel, equipments
and management standards: The Community Health Centres were designed to
function as institutions to provide secondary level of health care to the rural
population. The state has 227 Community Health Centers. However, most of
these are not fulfilling their envisaged tasks. The National Rural Health Mission
has developed Indian Public Health Standards to ensure that the Community
Health Centers are able to provide good quality specialist health care to the
rural population. These standards describe the services that should be
available at Community Health Center. It includes routine and emergency care
in surgery, medicine, obstetric and gynecology and pediatrics and all the
National Health Programmes. These standards also prescribe the standards for
support services at CHC level. The minimum requirements in terms of staff,
skills, equipment, drugs, investigated facilities, physical infrastructure including
electricity, telephone, water and sanitation have been prescribed.
The state has decided that a minimum of 2 Community Health Centers per
district will be identified for strengthening to meet IPHS in the year 2006 and
remaining Community Health Centers by year 2007.
The state has identified the gaps in human resource and skills. A process of
recruitment of specialists, Medical Officers and nursing staff on contractual
basis has been initiated. It is proposed that specialists in gyne. and obstetric,
anesthesia and pediatrics will be hired on contract basis on a fixed emolument
of Rs. 18000/- per month. In addition a provision has been made to pay an
incentive of upto Rs. 10000/- per month based on performance. The Medical
Officers and nursing staff will also be hired on contract basis. The skill gaps in
existing staff and newly recruited staff will be addressed by offering in-service
training.
The earlier experience of the state indicates that despite offering higher
remuneration and incentives specialists in gynecology and obstetric and
anesthesia do not join public services particularly in less developed areas. To
overcome this problem it is also proposed that Medical Officers will be trained
for a longer duration (4-6 months) in anesthesia, pediatrics and gynecology.
These Medical Officers after successful completion of training in the medical
colleges of the states will be posted in CEmONC facilities till qualified
specialists in these specialties are not available.
51
A facility survey of all CEmONC institutions have been undertaken to identify
the infrastructure gaps and assess the need for equipments and drugs. Based
on the findings this survey necessary maintenance, repair renovation work will
be undertaken to improve the infrastructure. The availability of running water
and power will be ensured by providing a genset. The necessary equipments,
drug and supplies as per IPHS will be ensured at all CEmONC facilities.
The blood bank at District Hospitals and blood storage facilities at other
CEmONC facilities will be developed or strengthened. The guidelines for blood
storage units prepared by MOHFW, Gol will be followed.
The hospital waste management system will be strengthened in each hospital
using the national guidelines on hospital waste management, which are based
on the bio-medical waste (management and handling) rules 1998. Accordingly,
the Infection Management and Environment Plan (IMEP) guidelines of Gol
would be followed by each institution. The staff involved in collection
segregation, transportation, treatment and disposal of hospital waste will be
trained and provided adequate safety equipments.
6.
Mainstreaming of AYUSH Systems in the National Health Care Delivery
System
The term AYUSH covers Ayurveda, Yoga & Naturopathy, Unani, Siddha and
Homeopathy. These systems are popular in a large number of States in the
country. The Ayurveda system is popular mostly in the States of Kerala,
Himachal Pradesh, Gujarat, Karnataka, Madhya Pradesh, Rajasthan, Uttar
Pradesh and Orissa. The Unani system is particularly popular in Andhra
Pradesh, Karnataka, Tamil Nadu, Bihar, Maharashtra, Madhya Pradesh, Uttar
Pradesh, Delhi and Rajasthan. The Siddha system is widely acceptable in
Tamil Nadu and Kerala. The Homeopathy is practiced all over the country but
primarily popular in Uttar Pradesh, Kerala, West Bengal, Orissa, Andhra
Pradesh, Maharashtra, Punjab, Tamil Nadu, Bihar, Gujarat and North-Eastern
States. This is to imply that the AYUSH systems of medicine and its practices
are well accepted by the community, particularly, in rural areas. The medicines
are easily available and prepared from locally available resources, economical
and comparatively safe. With this background, the Gol has proposed to
mainstream/integrate AYUSH systems in National Health Care Delivery System
under “National Rural Health Mission (NRHM)”.
52
Presently, there are 194 AYUSH Hospitals and dispensaries existing in the
rural areas of the State. These include 8 hospitals and 186 AYUSH
dispensaries.
For mainstreaming of AYUSH in NRHM, the personnel of AYUSH shall work
under the same roof of the Health Infrastructure, i.e., PHC, CHC. However,
separate space would be allocated exclusively for them in the same building.
The Doctors under the Systems of AYUSH are required to practice as per the
terms & conditions laid down for them by the appropriate Regulatory
Authorities. Following provisions have been made under the NRHM:
•
Provision of one Doctor of any of the AYUSH systems as per the local
acceptability assisted by a Pharmacist in PHC.
•
Provision of one Specialist of any of the AYUSH systems as per the local
acceptability assisted by a Pharmacist in CHC.
•
Supply of appropriate medicines pertaining of AYUSH systems.
•
The already existing AYUSH infrastructure to be mobilized. AYUSH
dispensaries that are not functioning well should be merged with the PHC or
CHC barring which, displacement of AYUSH clinic is not advised.
•
Cross referral between allopathic and AYUSH streams shall be encouraged
based on the need for the same.
•
AYUSH Doctors shall be involved in IEC, health promotion and also
supervisory activities.
NRHM
implementation
guidelines
provide
integration
of
AYUSH
with
community health centers and district hospitals. The adequate space will be
provided at CHCs and District Hospitals for the doctors of AYUSH and the
drugs of AYUSH system will also be procured and arranged.
AYUSH has a wide network of practitioners in the State and it provides reliable,
effective and economic alternative health services to the people. Considering
the fact that AYUSH systems of medicine which include Ayurveda, Unani and
Homeopathy are popular and acceptable to people, mainstreaming this system
in the health care delivery could contribute better synergy and utilization of
AYUSH practitioners in the State. NRHM envisages for mainstreaming of
AYUSH in health care delivery system of the State. There are 17 district level
ayurvedic hospitals located at Bhopal, Hoshangabad, Betul, Shivpuri, Morena,
53
Mandla,
Khargone,
Jhabua,
Dhar,
Ratlam,
Mandsaur,
Sagar,
Damoh,
Chhatarpur, Sidhi, Shahdol and Satna. There are four ayurvedic hospitals at
tehsil level at Rau (Indore), Tamia (Chhindwara), Beihar (Balaghat) and
Lakhnadoan (Seoni) and two homeopathy hospitals at Navegaon Sanitorium
(Chhindwara) and Pithampur (Dhar), in addition to these institutions there are
1427 single doctor ayurvedic dispensaries of which 61 are urban and 1366 are
rural. Likewise there are 50 Unani dispensaries, of which 27 are located in
urban area and 23 are located in rural area. There are 146 single doctor
dispensaries of which 64 are in urban areas and 82 in rural areas.
NRHM guidelines provide that each Community Health Center must provide
adequate space for AYUSH practitioners and also make provisions for AYUSH
medicines. In the State out of 265 CHCs only 28 CHCs have AYUSH doctors. It
is proposed that 200 AYUSH doctors will be engaged on contract basis for
CHCs / PHCs along with 200 Pharmacists. Adequate provisions will be made in
the NRHM programme for AYUSH drugs and documentation of traditional
practices, promoting healthy life styles and other related activities.
7.
Support to Rogi Kalyan Samitis for community management of hospitals
and annual maintenance of the facilities
The National Rural Health Mission guidelines provide a corpus grant for
hospital management societies. It is proposed that a sum of Rs. 5 Lakhs per
district hospital, Rs.1 lakh each per Civil Hospital, CHC and PHC will be
provided
as
an
incentive formation
and
operationalisation
of hospital
management societies. It is envisaged that the hospital management societies
will promote social audit for provision of quality health services and will
contribute to creation of a fund at the facility level through levy of user charges
on the services available at the institution.
Madhya Pradesh is one of the pioneering states where hospital management
societies (Rogi Kalyan Samitis) were established and operationalized at all
health institutions up to the level of primary health centres. To take advantage
of the scheme of MOHFW, Gol of providing corpus grant for hospital
management societies all CHCs, sub-district hospitals and district hospitals
where the Rogi Kalyan Samitis have been registered and are operational, will
be eligible for this grant.
54
8.
Mobile Medical Units
NRHM guidelines propose that one Mobile Medical Unit will be provided in each
district to improve outreach of services.
The state had been using mobile medical services to increase the reach of
medical and
health services to inaccessible areas and
disadvantaged
population groups. The state launched a scheme called Jeewan Jyoti Yojana in
1988-89 with the assistance from Govt, of India to provide mobile medical
services in tribal areas on Hat-Bazaar days. Under this scheme 39 mobile
medical units were obtained and provided to the districts. Later in the year 2003
10 mobile health units were provided 2 per district in 5 IPDP districts namely
Chhatarpur, Panna, Rewa, Satna and Sidhi. These mobile health units were
equipped with generator, inverter, minor OT with OT table and lights, oxygen
cylinder and facilities for running water. These mobile health units had facilities
for examining patients and conducting minor surgical interventions. The
experience of the state of using mobile medical units and mobile health units for
providing medical and health services in unreached areas had been a mix one.
Organizing health services through mobile medical / health units requires
intensive management inputs and sustained provisions for POL, maintenance
and availability of staff and provisions for drugs. Considering the constraints
faced by the state and learning from previous experiences this time the state
proposes to involve private sector in running mobile medical / health units in the
state.
The mobile medical / health units will be run in all 48 districts. For this purpose
one mobile health unit with diagnostic facilities and a staff vehicle per district
will be procured as per the guidelines of NRHM.
The mobile health units will be used to improve the access and availability of
health services in remote and difficult reach areas. These units will be run
through RKS / NGOs / Public Private Partnerships. Appropriate budget
provisions as per the guidelines for recurring expenditure have been made in
the proposal.
9.
Preparation of District Health Action Plan
The NRHM provides for an allocation of Rs.20 lakhs per district for preparation
of District Health Action Plans. The amount can be used for surveys,
55
workshops, studies, consultations, orientation in the process for preparation of
District Health Action Plans.
The State has already instituted the mechanism and process for preparation of
district plans since year 2004. Going by the experiences of the recently
concluded
appraisal
of 48
districts’
action
plans, the State plans to
institutionalize the process of preparation of integrated district health action
plans. Consequently, it is proposed that the planning for formulating the district
plans for 2007-08 shall be initiated in the month of December 2006. The State
intends to utilize the allocation for plan preparation in terms of the following:
•
Enhancing capacities of programme managers at State, district and sub
district levels.
•
Development and updation of district data sets.
•
Development of computerized authoritative specifications for equipments,
instruments and supplies.
•
Development of computer-aided standard civil and architectural designs for
building constructions.
10.
Setting up State Health Systems Resource Centre
The NRHM provides an allocation of Rs. 1 Crore for this. The detailed ToRs on
its functionality and its linkage with the State Government would be determined.
The state proposes to establish the State Health Systems Resource Center to
enable innovations and channelise coordinated technical assistance in the
areas of strategic planning, technical assistance and operational support. The
State desires that the UNFPA, being the assigned Development Partner for the
state may be requested for creation, supporting and backstopping the SHSRC.
The similar resource centers would be created at the district and block levels
subsequently and the State Health Systems Resource Centre will function as
an apex resource centre in the State.
11.
Preparation of State and district public report on health
The NRHM provides for Rs. 2 lakhs for the State and Rs. 25,000/- per district
for this activity. The respective reports would be generated based on a
standardized format through outsourcing. Initially, it is proposed to prepare this
report for 10 districts in year 1 and the State Report. From year 2 onwards the
State Report and the District Reports for all the districts will be prepared on
annual basis.
56
12.
Strengthening of ANM Training Centers
The State has 27 ANM training centers with a capacity to train 1620 trainees.
Considering the requirement of ANMs in the State, State needs to augment its
training capacity. It is proposed that ANM training school will be created in all
the districts of the State, for this 21 new training centers will be created. The
existing 27 training institutions also need strengthening in terms of repair /
renovation, extension, training equipments, furniture and other basic amenities.
Out of 27 existing ANM training centers, 7 are running in rented and / or
makeshift accommodation like DTC, District Hospital and CHC, which are
inadequate for the purpose of training. Therefore it is proposed that buildings
for 28 ANM training schools are constructed and equipped. Each ANM Training
School will be provided with mobility support for transporting trainees to the
attached hospital and community for training purpose.
13.
Enhancing Training Capacity for Training ANMs through Public Private
Partnership
There is a wide gap between the demand of trained ANMs and the available
capacity in the public sector in the State. Even after setting up new ANM
training centres in remaining 19 districts the gap between demand and supply
will continue to exist. To further enhance the training capacity, the State
proposes to promote public private partnership. Upto 10 ANM training schools
will be supported for three consecutive batches of ANM training.
14.
Strengthening of LHV Training Centres
There are two LHV training centres in the State. These centres need
strengthening in terms of repair / renovation, maintenance of the building and
training equipments and upgrading library facilities. For this purpose it is
proposed to provide Rs. 50,000/- each during year 1, Rs. 2.5 Lakhs each
during year 2 and Rs. 2 Lakhs each in year 3.
15.
Strengthening of Nursing Training Schools
There are 11 Nursing Schools in the State.
Capacity
S.No.
Name of the Training Center
1.
Hamidia Hospital, Bhopal
35
2.
M.Y. Hospital, Indore
41
3.
J.A. Hospital, Gwalior
41
57
4.
Medical College Hospital, Jabalpur
47
5.
G.M. Hospital, Rewa
32
6.
Victoria Hospital, Jabalpur
25
7.
District Hospital, Chhindwara
10
8?
District Hospital, Ujjain
17
9.
District Hospital, Khandwa
10
10.
District Hospital, Sagar
10
11.
District Hospital, Ratlam
10
Total
278
These nursing schools needs strengthening in terms of repair / renovation,
extension, equipments and basic amenities. In the year 1 a need assessment
study will be undertaken. Based on the study findings the strengthening
activities will be undertaken during year 2 and year 3 for which a sum of Rs. 2
Lakhs per Nursing School will be provided respectively except for the nursing
schools in Jabalpur and Ujjain. For these nursing schools a separate has been
received from Gol for upgrading them to Nursing Colleges.
16.
Quality Assurance
A system of accreditation will be introduced on a pilot basis in two districts. The
Quality Counsel of India will undertake this work. Based on the experience of
this pilot a decision for up-scaling this intervention will be taken. All the districts
will be covered under this programme in phased manner. This intervention will
also be coordinated with timeline of strengthening health institutions under
IPHS standards.
17.
Health Melas
Swasthya Melas will be organized one per district and one at block level in all
the districts. This way 48 district level and 265 block level health melas will be
organized. For district health melas a sum of Rs. 5 Lakhs per mela and for
block level melas Rs. One lakh per mela will be sanctioned. These melas will
be organized every year from year 2 onwards.
18.
Mobility Support for Block Medical Officers
Block Medical Officers need to conduct supervisory visits to the sub centers
and primary health centers as well as maintain contact with PRIs. In order to
facilitate their mobility, it is proposed to provide hired vehicle on a monthly basis
58
to all the Block Medical Officers. This will not only improve the monitoring and
supervision of different national health programmes but will also help in
promptly investigating disease outbreaks and organizing rapid response. A
provision of Rs. 15,000/- per month per block is proposed. For the year 200607 a provision has been made for mobility support for 3 months only.
19.
Health Insurance
19.1
Social Insurance
Recognizing that the poor are quite vulnerable to diseases, natural and other
disasters, the State has considered it prudent to bring them under the net of
social insurance. It is proposed to purchase an insurance cover for 45 Lakhs
BPL families at a premium of Rs. 51/- per family per year, this insurance
coverage will cover medical and surgical disease conditions.
19.2
Maternity Insurance
The State has introduced Vijaya Raje Janani Kalyan Beema Yojana from July
2006 with the objective promoting institutional deliveries amongst all BPL
women. Both the response and uptake of the scheme has been very
encouraging. The State has therefore decided to continue with the scheme so
that its advantages may accrue to all pregnant women belonging to BPL.
During the year 2006-07, Rs. 6 Crores has been paid to the insurance company
as the initial installment of the premium from the DFID funded project. The
balance amount of premium will be paid from the NRHM.
20.
Supply of Essential Drugs for PHCs and CHC
The State provides a budget of Rs. 5,000/- per sub center, 1,00,000/- per PHC
and 2,00,000/- per CHC per annum for procurement of drugs. To enhance the
availability of all essential drugs and to ensure that all poor patients are
provided free drugs, a need has been appreciated for augmenting this budget.
An additional allocation of Rs. 10000/- per sub centre, Rs. 2 Lakhs per PHC
and Rs. 4 Lakhs per CHC has been proposed.
21.
Drug Stores
The State has drug stores at 28 districts out of the total 48 districts. The State
has decided to introduce a centralized procurement and distribution system
based on the Tamil Nadu Drug Corporation. In order to have smooth
distribution and storage of drugs in all the districts it is proposed to construct
59
drug stores at remaining 20 districts. Cost of construction a drug store will be
Rs. 40 Lakhs. The construction of the new drug stores will be undertaken in the
year 2007-08.
The drug procurement cell of the Directorate will be strengthened with the
introduction of e-procurement. A provision for covering the cost of setting of the
office and its running cost has been made.
22.
Facility Survey of CHCs / PHCs
It is proposed to undertake a facility survey of all 48 district hospitals, 54 civil
hospitals, 127 CEmONC and 500 BEmONC institutions and non-BEmONC
PHCs to identify gaps and infrastructure, repair / renovation requirements, gaps
in human resource and equipments. The study will cost approximately Rs. 1.5
crores for district hospitals, Rs. One crore for civil hospitals, Rs. 2.54 crores for
CHCs and Rs. 5 crores for PHCs. It is proposed that during 2006-07 the facility
survey will be conducted for 2 district hospital, 5 civil hospitals, 12 CHCs and
50 PHCs, during year 2 for 46 district hospitals, 49 civil hospitals, 115 CHCs
and 450 PHCs.
23.
Research and Evaluation
Role of operations research needs to be optimized for improving programme
performance as well as for improving the quality of programme implementation
and monitoring. The State would establish an Operations Research Cell, which
will
coordinate all
operational
researches
and
maintain
a
catalogued
documentation. This cell would be appropriately manned with requisite
professionals having expertise in public and related disciplines including
research methodology. The State would also seek to strengthen monitoring and
evaluation system so that effective HMIS is put in place. In addition, the state
proposes to develop and document best practices so that the programme
implementers can benchmark their performances. The state Government would
also specifically include E-governance and telemedicine in its operations
research agenda. The detailed work plan would be developed to address these
initiatives.
The Cell would specifically undertake a pilot project on prevention of anemia
among tribal women. This project would seek to meet the IFA supplementation
60
needs of seven lakhs pregnant women and lactating mothers across 89 tribal
blocks through consumption of double fortified common salt. Baseline and
endline surveys will be conducted to determine the performance of the
intervention.
It is also proposed to commission a series of studies, both short term and long
term in order to continually assess maternal health outcomes. Towards this end
process indicators captured through institution based MIS would be analyzed
and interpreted through such analytical studies. The appropriate TORs shall be
developed for these studies and an amount of Rs. 1.5 crores shall be kept apart
for remitting to the individual experts / agencies who are assigned these
studies.
In addition, the other activities under research and evaluation would include
developing and instituting e-governance, HMIS and Tele-Medicine.
24.
Networking with NGOs and Professional Organizations
With a view to strengthening grass root level advocacy as well as availability of
health care services, the State proposes to strengthen the network of NGOs in
health and allied sectors. These NGOs would include all such non-government
organizations whether they are new or old and they may be functioning as
voluntary organizations (VOs), community based organizations (CBOs) and
such other civil society organizations (CSOs). It is important here to underline
the fact that when it comes to NGOs, it would not be necessary for them to be
registered organizations, per se. What is more important in the proposed
networking of civil society organizations to bring about synergistic action
amongst them so that effective advocacy in health and allied sectors can
become more pronounced. The efforts will be made to identify such purposive
organizations / movements (like White Ribbon Alliance for Safe Motherhood,
Breastfeeding Promotion Network of India etc.). However, social clubs like
rotaries, lions, inner-wheel club etc. would not be considered as NGOs for this
purpose. The professional organizations like FOGSI, IMA, IPA, IPHA, IAPSM,
Private Practitioners’ Association etc. would be having primacy in their roles in
this networking.
61
25
Addition of Gyne. And Pediatric Ward in District Hospitals
Institutional deliveries have registered a significant increase of 20% in last year
as a result of various innovative schemes implemented in the State to promote
institutional deliveries. It is expected that proportion of the institutional deliveries
will increase to a level of 50% by next year. To meet the increased demand of
institutional deliveries there is an urgent need for expansion of capacities of
district hospitals especially terms of bed capacity in Gynec. and Pediatric
Wards. It is proposed to add 20 beds in each speciality in each district hospital.
During the year 1, the expansion work will be undertaken in 5 districts and in
year all district hospitals will be covered. The recurring expenditure on the
enhanced bed capacity will be borne by the State from its own sources and / or
different other programmes.
26
Behavioural Change Communication (BCC)
Behavioural change communication is an important thrust area under NRHM.
The State intends to determine behavioural change communication needs of
the community on different thematic areas apart from identifying and supporting
the specific communication roles which different committees are required to
play at different levels of governance. Following the identification of BCC
needs, district and region specific communication plans for different audience
segments would be developed and implemented. It is also a perceived need
that the tenets of NRHM require to be widely disseminated. For this purpose,
both at the block as well as district levels, intensive programme communication
drive would be carried-out by way of workshops for different stakeholders.
27
Capacity Building of PRIs
The PRIs constitute the third-tier of governance and have crucial roles in
surveillance in public health system in mobilizing the community for positively
altering its health seeking behaviour. Given the fact that these elected
representatives are changed every five years, it is necessary to have a
continuity of communication and dialogue with them so that they may effectively
discharge their roles vis-a-vis the NRHM programme. The State has therefore
determined to institute a continued initiative of capacity building of the PRIs at
village, Gram Panchayat, Janpad Panchayat and Zila Panchayat levels. It is
hoped that with this investment the PRIs would be able to play their designated
roles in planning, implementation and monitoring of community health plans.
62
28.
Support to FOGSI
RCH-II Programme guidelines provide that FOGSI will coordinate and organize
training of medical officers in emergency obstetric care including caesarian
sections. These trainings will be organized by FOGSI specialists for the MOs of
both public and private institutions. To strengthen the training sites Rs. 40
Lakhs will be required. The training sites at two medical colleges will be
developed and strengthened, one during 2006-07 and the other in 2007-08.
One of these sites will be upgraded to the level of similar unit at CMC Vellore.
29.
Strengthening Blood Banks
The State proposes to strengthen the management of State Blood Transfusion
Council so that it may effectively play its mandated role. The requisite facilities
including manpower on contract would be made available to the council’s office
which will be located in the Directorate of Health Services.
The State has 5 blood banks in the medical colleges, 36 blood banks in district
hospitals and 50 blood banks in private sector. It is proposed to network these
blood banks so as to optimize the availability of blood especially of rare groups.
All the blood banks will be inter-connected through a network of computers and
a special software will be developed. For this purpose Rs. 40 Lakhs will be
required for developing software and training.
The five blood banks are providing blood components. The medical social
workers (10) of these blood banks will be trained on donor motivation and
social marketing by an agency ‘Prathima Blood Center, Ahmedabad (Gujarat)’.
It is a 15-day training. Cost of one training for 10 participants including training
fee, TA/DA of participants and per diem is Rs. 1,27,500/-. This training will be
done in a batch of 3 participants per training programme.
30.
Creation of Disaster Management Cell
It has been decided that a state level Disaster Management Cell will be created
in the Directorate of Health Services, Bhopal as per the guidelines of National
Disaster Management Authority, this cell will formulate and implement state
contingency plan to deal with disaster situations arising out of changes in
climate, accidents, chemical and industrial hazards and geological and
biological disasters. This Cell will also plan and manage the appropriate
resource inventory and position identified emergency wards both in the public
63
as well as private hospitals. The initiative will also include constitution multi
disciplinary rapid response teams which will be duly trained in taking proactive
as well as responsive steps in managing natural and man-made disasters. On
the similar lines district level rapid response teams will also be created, trained
and equipped. It involves the following:-
•
Identification of appropriate physical space for the Cell, provision for its
furnishing and procurement of communication equipments.
•
The training of district and state level rapid response teams.
•
Preparation of district and state level disaster preparedness plans which
should include inventorization of resources and the logistics involved
therein.
•
Enabling structures for ensuring inter-sectoral coordination both at the state
and district level.
31.
School Health Programme
The school health programme will be further strengthened to provide regular
health check-up and health care services for all school going children. Sick
children suffering from common illness will be treated by the local institutions
while sick children requiring higher level of care will be referred to secondary
and tertiary care health institutions. Health education and improving the
hygiene will be an important component of the programme.
32.
Ambulance Services
It has been decided that two ambulances per District Hospital and one
ambulance per Civil Hospital, CHC and PHC will be procured and provided to
these institutions for being run through RKS / PPP mode. During the year 1,48
ambulances for district hospitals, 50 ambulances for CHCs, 10 ambulances for
civil hospitals will be procured. During the year 2, 48 ambulances will be
procured for district hospitals, 216 ambulances for CHCs, 45 ambulances for
civil hospitals and 383 ambulances for PHCs. During year 3, 769 ambulances
will be procured for PHCs. Thus in all, 108 ambulances will be procured during
2006-07, 383 ambulances during 2007-08 and 769 ambulances during 200809. A provision has been made in the proposal for providing running cost for
these ambulances @ Rs. 15000/- ambulance per month.
64
33.
District Mental Health Programme
The prevalence of mental disorder is one of the major Mental Health Problem of
the state as we know more than 2% of the population of the state suffers from
serious mental disorder and another 15-20% of the population suffers from
minor mental disorders. As per WHO, depression is the 4th leading cause of
morbidity all over the world. Apart from this 30-40% of the patients who attend
general
OPD
of various
other clinical
department
require
psychiatric
consultation. Not only this, after delivery more than 50% of the women develop
either depression or other psychiatric disorder. As regards school mental
health, there are no facilities for early identification and treatment of various
psychiatric disorders among children. As we know 15-20% children require
psychiatric help. One percent of the population of the country is suffering from
severe mental retardation. Drug addiction is another major mental health
problem, which requires early intervention and treatment. There is no proper
rehabilitation facility in the state of Madhya Pradesh for mentally ill patients
including mentally retarded ones. As we know, psychiatric problems are quite
common among old age people and they need better care. The magnitude of
the problem is very high but the facilities are inadequate.
Each district of Madhya Pradesh must have mental health unit, which must be
headed by a psychiatrist. Unit should have one psychiatrist, one psychologist,
one psychiatric social worker and 10 beds for admission. District Hospitals
should have needed infrastructure and staff as per norms. For proper
investigation and treatment, EEG, ECT and psychological tests facilities should
be provided in the district hospitals.
For meeting the demand of psychiatrists in the districts, the department of
psychiatry in medical colleges should start teaching and training program of
medical officers and P.G. (MD) in Psychiatry. Required technical assistance
may be sourced from the department of psychiatry, NIMHANS Bangalore and
AllMS New Delhi. The State Government may recruit required staff on contract.
34.
Convergence with MPSACS
Keeping in view the fact that presently National Aids Control Organization does
not
have
sub-district institutional
presence,
it is
proposed to
institute
appropriate strategies for bringing about integration between RCH and AIDS
65
Control Programme at sub-district levels. The proposed convergence will
include the following activities:-
•
Orientation training of ASHA workers in consultation with MPSACS
•
Orientation of ASHA workers in consultation with MPSACS.
•
Sensitization of ANMs, LHVs, Staff Nurses, Lab. Technicians and Medical
Officers.
These
activities
will
be
undertaken
in
conjunction
with
programme
implementation plan of MPSACS.
35.
Strengthening Referral Services and Tertiary Care Units
The tertiary care health institutions plan an important role in providing critical
health care to women and children. The primary and secondary health
institutions refer serious and complicated cases for further management. The
current system of referral needs improvement and strengthening at the tertiary
care level. To fulfill this objective it is proposed that all the 5 medical colleges
will be strengthened appropriately during year 2 and year 5 of the programme.
36.
NRHM Management
NRHM guidelines provide for 6% of the total budget to be utilized for
programme management costs. It is proposed that the State would utilize these
funds for creating and supporting appropriate management structures at State,
district and block levels. It is also proposed that the management costs would
also be used for defraying the costs towards recently created divisional level
offices of Joint Directors apart from strengthening the offices of CMHOs and
BMOs.
66
/\nnexure-ll
ABBREVIATIONS
AllMS
ANM
ARI
ASHA
AWW
AYUSH
BEmONC
BPL
CBO
CEmONC
CH
CHC
CMHO
CMR
CSO
DFID
DH
DP
DTC
EEG
FNGO
FOGSI
GOI
HMIS
HRD
IAP
IAPSM
ICDS
ICRIER
IEC
I FA
IMA
IMNCI
IMR
IPDP
IPHA
IPHS
IUCD
JSY
LHV
M&E
MDG
MNGO
MOHFW
MoU
MP
MPSACS
MPW
MTP
All Indian Institute of Medical Science
Auxiliary Nurse Midwife
Acute Respiratory Infection
Accredited Social Health Activist
Aanganwadi Worker
Ayurved Siddha and Homeopathy
Basic Emergency Obstetric Neonatal Care
Below Poverty Line
Community Based Organization
Comprehensive Emergency Obstetric Neonatal Care
Civil Hospital
Community Health Centre
Chief Medical and Health Officer
Child Mortality Rate
Civil Society Organization
Department for International Development
District Hospital
Development Partners
District Training Centre
Electro Encephalogram
Field Non-Governmental Organization
Federation of Obstetric and
Government of India
Health Management Information System
Human Resource Development
Indian Association of Pediatrics
Indian Association of Preventive and Social Medicine
Integrated Child Development Scheme
Indian Council of Research
Information Education and Communication
Iron Folic Acid
Indian Medical Association
Integrated Management of Neonatal and Childhood Illnesses
Infant Mortality Rate
Integrated Population and Development Project
Indian Public Health Association
Indian Public Health Standards
Inter Uterine Contraceptive Devices
Janani Suraksha Yojana
Local Health Visitor
Monitoring and Evaluation
Millennium Development Goals
Mother Non-Governmental Organization
Ministry of Health and Family Welfare
Memorandum of Understanding
Madhya Pradesh
Madhya Pradesh State AIDS Control Society
Multi-Purpose Worker
Medical Termination of Pregnancy
67
NACO
NACP
NCAER
NFHS
NIMHANS
NMR
OBC
ORD
PG
PNC
PHED
PHPY
PIP
PMU
POL
PRI
RCH
RHS
RKS
RMP
RTI
SBA
SC
SHC
SHSRC
SNGO
SPMU
ST
STI
TBA
TFR
TT
U5M
UIP
UNFPA
UT
VHSC
VO
National AIDS Control Organization
National AIDS Control Programme
National Council for Applied and Economic Research
National Family Health Survey
National Institute of Mental Health and Neuro Sciences
Neonatal Mortality Rate
Other Backward Class
Outdoor Patient Dispensary
Post Graduate
Primary Health Centre
Public Health Engineering Department
Prasav Hetu Parivahan Yojana
Programme Implementation Plan
Programme Management Unit
Petrol Oil and Lubricant
Panchayati Raj Institution
Reproductive and Child Health
Rapid Household Survey
Rogi Kalyan Samiti
Registered Medical Practitioner
Reproductive Tract Infection
Skilled Birth Attendant
Scheduled Caste
Sub Health Centre
State Health Systems Resource Centre
Service Non-Governmental Organization
State Programme Management Unit
Scheduled Tribe
Sexual Tract Infection
Traditional Birth Attendant
Total Fertility Rate
Tetanus Toxoid
Under 5 Mortality
Universal Immunization Programme
United Nations Population Fund
Union Territory
Village Health and Sanitation Committee
Voluntary Organization
68
DRAFT REPORT ON RECOMMENDATION OF TASK FORCE ON PUBLIC PRIVATE
PARTNERSHIP FOR THE 11™ PLAN
The Planning Commission constituted a Working Group on Public Private Partnership to
improve health care delivery for the Eleventh Five-Year Plan (2007-2012) under the
Chairmanship of Secretary, Department of Health & Family Welfare, Government of India with the
following members:
1.
Secretary, Department of Health & Family Welfare, New Delhi
Chairman
2.
Secretary (Health), Government of West Bengal
Member
3.
Secretary (Health), Government of Bihar
Member
4.
Secretary (Health), Government of Jharkhand
Member
5.
Secretary (Health), Government of Karnataka
Member
6.
Secretary (Health), Government of Gujarat
Member
7.
Director General Health Services, Directorate General of Health Services,
Member
New Delhi
8.
President, Indian Medical Association, New Delhi
Member
9.
Medical Commissioner, employees State Insurance Corporation, New
Member
Delhi
10.
Dr. H. Sudarshan, President /Chairman, Task Force on Health & Family
Member
Welfare, Government of Karnataka, Bangalore
11.
Dr. Sharad Iyengar, Action Research & Training in Health, Udaipur,
Member
Rajasthan
12.
Executive Director, Population Foundation of India, New Delhi
Member
13.
Dr. S.D. Gupta, Director, Indian Institute of Health Management Research,
Member
Jaipur
14.
Ms. Vidya Das, Agragamee, Kashipur, District Rayagada, Orissa
Member
1
15.
Dr. C.S. Pandav, Centre for Community Medicine, All India Institute of
Member
Medical Sciences, New Delhi
16.
Dr. V.K. Tiwari, Acting Head, Department of Planning & Evaluation,
Member
National Institute of Health & Family Welfare, New Delhi.
17.
Dr. A Venkat Raman, Faculty of Management Sciences, University of
Member
Delhi
18.
Dr. K.B. Singh, Technical Adviser, European Commission, New Delhi
Member
19.
Shri K.M. Gupta, Director, Ministry of Finance, New Delhi
Member
20.
Shri Rajeev Lochan, Director (Health), Planning Commission, New Delhi
Member
21.
Joint Secretary, Ministry of Health & Family Welfare, New Delhi
Member
Secretary
The Terms of reference of the Working Group were as under:
(i)
To review existing scenario of Public Private Partnership in health care (Public,
Private, NGO) in urban and rural areas with a view to provide universal access to equitable,
affordable and quality health care which is accountable at the same time responsive to the needs
of the people, reduction of child and maternal deaths as well as population stablization and also
achieve goals set under the National Health Policy and the Millennium Development Goals.
(ii)
To identify the potential areas in the health care delivery system where an effective,
viable, outcome oriented public private partnership is possible.
(iii)
To suggest a practical and cost effective system of public private partnership to
improve health care delivery system so as to achieve the goals set in National Rural Health
Mission, National Health Policy and the Millennium Development Goals and makes quantitative
and qualitative difference in implementation of major health & family welfare programmes,
functioning of health & family welfare infrastructure and manpower in rural and urban areas.
(iv)
To deliberate and give recommendations on any other matter relevant to the topic.
2
DEFINING PUBLIC PRIVATE PARTNERSHIP IN HEALTH
Public-Private Partnership or PPP in the context of the health sector is an instrument for
improving the health of the population. PPP is to be seen in the context of viewing the whole
medical sector as a national asset with health promotion as goal of all health providers, private or
public. The Private and Non-profit sectors are also very much accountable to overall health
systems and services of the country. Therefore, synergies where all the stakeholders feel they
are part of the system and do everything possible to strengthen national policies and programmes
needs to be emphasized with a proactive role from the Government.
However for definitional purpose, “Public” would define Government or organizations
functioning under State budgets, “Private” would be the Profit/Non-profit/Voluntary sector and
“Partnership" would mean a collaborative effort and reciprocal relationship between two parties
with clear terms and conditions to achieve mutually understood and agreed upon objectives
following certain mechanisms.
PPP however would not mean privatization of the health sector. Partnership is not meant
to be a substitution for lesser provisioning of government resources nor an abdication of
Government responsibility but as a tool for augmenting the public health system.
THE ROLE OF THE PRIVATE SECTOR IN HEALTH CARE
I
!•
2
Utilisation of Hospital Services
8,000
7,000
6,000
■ Private
g Public
5,000
4,000
3,000
2,000
!
1,000
Hw I
xr
I
.er
o*
Source Pearson M, Impact and Expenditure Review, Part II Policy issues. DFID, 2002
Over the years the private health sector in India has grown markedly. Today the private
sector provides 58% of the hospitals, 29% of the beds in the hospitals and 81% of the doctors.
(The Report of the Task Force on Medical Education, MoHFW)
The private providers in treatment of illness are 78% in the rural areas and 81% in the
urban areas. The use of public health care is lowest in the states of Bihar and Uttar Pradesh. The
reliance on the private sector is highest in Bihar. 77% of OPD cases in rural areas and 80% in
urban areas are being serviced by the private sector in the country. (60th round of the National
Sample Survey Organisation (NSSO) Report.
3
The success of health care in Tamil Nadu and Kerala is not only on account of the Public
Health System. The private sector has also provided useful contribution in improving health care
provision.
Studies of the operations of successful field NGOs have shown that they have produced
dramatic results through primary sector health care services at costs ranging from Rs. 21 to Rs.
91 per capita per year. Though such pilot projects are not directly upscalable, they demonstrate
promising possibilities of meeting the health needs of the citizens by focused thrust on primary
healthcare services. (NSSO 60th Round)
India: Percentage of Hospitalizations In The Public and Private
Sector Among Those Below The Poverty Line, According To State
100% TT-]
CD
U)
05
4-’
c
0)
o
k.
0)
CL
80% 60%
.j
-
:■
—
40%
20%
0%
/
/
/
//
/
/
/
/
/
6'
/
States
Public Facilities
Private Facilities
Source Pearson M, Impact and Expenditure Review, Part II Policy issues. DFID,2002
While data and information is still being collated, the private health sector seems to be the
most unregulated sector in India. The quantum of health services the private sector provides is
large but is of poor and uneven quality. Services, particularly in the private sector have shown a
trend towards high cost, high tech procedures and regimens. Another relevant aspect borne out
by several field studies is that private health services are significantly more expensive than public
health services - in a series of studies, outpatient services have been found to be 20-54% higher
and inpatient services 107-740% higher. (Report of the Task Force on Medical Education,
MoHFW.
Widely perceived to be inequitable, expensive, over indulgent in clinical procedures, and
without standards of quality, the private sector is also seen to be easily accessible, better
managed and more efficient than its public counterpart.
4
Given the overwhelming presence of private sector in health, there is a need to regulate and
involve the private sector in an appropriate public-private mix for providing comprehensive and
universal primary health care to all. However there is an overwhelming need for action on
privatization of health services, so that the health care does not become a commodity for buying
and selling in the market but remains a public good, which is so very important for India where
1/3 of the population can hardly access amenities of life, leave alone health care.
In view of the non-availability of quality care at a reasonable cost from the private sector,
the upscaling of non-profit sector in health care both Primary, Secondary and Tertiary care,
particularly with the growing problems of chronic diseases and diseases like HIV/AIDS, needs
long term care and support.
OBJECTIVES OF PUBLIC PRIVATE PARTNERSHIPS
Universal coverage and equity for primary health care should be the main objective of any
PPP mechanism besides:
> Improving quality, accessibility, availability, acceptability and efficiency
> Exchange of skills and expertise between the public and private sector
> Mobilization of additional resources.
> Improve the efficiency in allocation of resources and additional resource generation
> Strengthening the existing health system by improving the management of health within
the government infrastructure
> Widening the range of services and number of services providers.
> Clearly defined sharing of risks
> Community ownership
REVIEW OF EXISTING SCENARIO OF PPP
POLICY PRESCRIPTION
Public-Private Partnership has emerged as one of the options to influence the growth of
private sector with public goals in mind. Under the Tenth Five Year Plan (2002-2007), initiatives
have been taken to define the role of the government, private and voluntary organizations in
meeting the growing needs for health care services including RCH and other national health
programmes. The Mid Term Appraisal of the Tenth Five Year Plan also advocates for
partnerships subject to suitability at the primary, secondary and tertiary levels. National Health
Policy-2002 also envisaged the participation of the private sector in primary, secondary and
tertiary care and recommended suitable legislation for regulating minimum infrastructure and
quality standards in clinical establishments/medical institutions. The policy also wanted the
participation of the non-governmental sector in the national disease control programmes so as to
ensure that standard treatment protocols are followed. The Ministry of Health and Family Welfare,
Government of India, has also evolved guidelines for public-private partnership in different
National Health Programmes like RNTCP, NBCP, NLEP, RCH, etc. However, States have varied
experiences of implementation and success of these initiatives. Under the Reproductive and
Child Health Programme Phase II (2005-2009), several initiatives have been proposed to
strengthen social-franchising initiatives. National Rural Health Mission (NRHM 2005-2012)
recently launched by the Hon’ble Prime Minister of India also proposes to support the
development and effective implementation of regulating mechanism for the private health sector
to ensure equity, transparency and accountability in achieving the public health goals. In order to
tap the resources available in the private sector and to conceptualize the strategies, Government
of India has constituted a Technical Advisory Group for this purpose, consisting of officials of
GOI, development partners and other stakeholders. The Task Group is in the process of finalizing
its recommendation.
5
REVIEW OF PPP IN THE HEALTH SECTOR
During the last few years, the Centre as well as the State Governments have initiated a wide
variety of public-private partnership arrangements to meet the growing health care needs of the
population under five basic mechanisms in the health sector:
> Contracting in-government hires individual on a temporary basis to provide services
> Contracting out- government pays outside individual to mange a specific function
> Subsidies-government gives funds to private groups to provide specific services
> Leasing or rentals-government offers the use of its facilities to a private organization
> Privatization-government gives or sells a public health facility to a private group
An attempt has been made here to encapsulate some of the on-going initiatives in public
private partnerships in selected states.
A. Partnership between the Government and the for profit sector
1. Contracting in Sawai Man Singh Hospital, Jaipur
• The SMS hospital has established a Life Line Fluid Drug Store to contract out low cost
high quality medicine and surgical items on a 24-hour basis inside the hospital. The agency
to operate the drug store is selected through bidding. The successful bidder is a proprietary
agency, and the medical superintendent is the overall supervisor in charge of monitoring the
store and it’s functioning. The contractor appoints and manages the remuneration of the staff
from the sales receipts. The SMS hospital shares resources with the drug store such as
electricity; water; computers for daily operations; physical space; stationery and medicines.
The contractor provides all staff salaries; daily operations and distribution of medicine;
maintenance of records and monthly reports to SMS Hospital. The SMS Hospital provides all
medicines to the drug store, and the contractor has no power to purchase or sell medicines
himself. The contractor gains substantial profits, could expand his contacts and gain
popularity through LLFS. However, the contractor has to abide by all the rules and
regulations as given in the contract document.
• The SMS Hospital has also contracted out the installation, operation and maintenance of
CT-scan and MRI services to a private agency. The agency is paid a monthly rent by the
hospital and the agency has to render free services to 20% of the patients belonging to the
poor socio-economic categories
2. The Uttaranchal Mobile Hospital and Research Center (UMHRC) is three-way partnership
among the Technology Information, Forecasting and Assessment Council (TIFAC), the
Government of Uttaranchal and the Birla Institute of Scientific Research (BISR). The motive
behind the partnership was to provide health care and diagnostic facilities to poor and rural
people at their doorstep in the difficult hilly terrains. TIFAC and the State Govt, shares the funds
sanctioned to BISR on an equal basis.
3. Contracting out of IEC services to the private sector by the State Malaria Control Society in
Gujarat is underway in order to control malaria in the state. The IEC budget from various
pharmaceutical companies is pooled together on a common basis and the agencies hired by the
private sector are allocated the money for development of IEC material through a special
sanction.
4. Contracting in of services like cleaning and maintenance of buildings, security, waste
management, scavenging, laundry, diet, etc. to the private sector has been tried in states like
Himachal Pradesh; Karnataka; Orissa (cleaning work of Capital Hospital by Sulabh International);
Punjab; Tripura (contracting Sulabh International for upkeep, cleaning and maintenance of the
G.B. Hospital and the surrounding area); Uttaranchal, etc.
5. The Government of Andhra Pradesh has initiated the Arogya Raksha Scheme in collaboration
with the New India Assurance Company and with private clinics. It is an insurance scheme fully
6
funded by the government. It provides hospitalization benefits and personal accident benefits to
citizens below the poverty line who undergo sterilization for family planning from government
health institutions. The government paid an insurance premium of Rs. 75 per family to the
insurance company, with the expected enrollment of 200,000 acceptors in the first year.
The medical officer in the clinics issues a Arogya Raksha Certificate to the person who
undergoes sterilization. The person and two of her/his children below the age of five years are
covered under the hospitalization benefit and personal accident benefit schemes. The person
and/oor her/his children could get in-patient treatment in the hospital upto a maximum of Rs. 2000
per hospitalization, and subject to a limit of Rs. 4000 for all treatments taken under one Arogya
Raksha Certificate in any one year. She/he gets free treatment from the hospital, which in turn
claims the charges from the New India Insurance Company. In case of death due to any accident,
the maximum benefit payable under one certificate is Rs. 10,000.
B. Partnership between the Government and the non-profit sector
1. Involvement of NGOs in the Family Welfare Programme
•
The MNGO (Mother NGO) and SNGO (Service NGO) Schemes are being implemented
by NGOs for population stabilization and ROH. 102 MNGOs in 439 districts, 800 FNGOs,
4 regional Resource Centers (RRC) and 1 Apex Resource Cell (ARC) are already in
place. The MNGOs involve smaller NGOs called FNGOs (Field NGOs) in the allocated
districts.
The functions of the MNGO include identification and selection of FNGOs; their capacity
building; development of baseline data for CAN; provision of technical support; liaison,
networking and coordination with State and District health services, PRIs and other
NGOs; monitoring the performance and progress of FNGOs and documentation of best
practices. The FNGOs are involved in conducting Community Needs Assessment; RCH
service delivery and orientation of RCH to PRI members; advocacy and awareness
generation.
The SNGOs provide an integrated package of clinical and non-clinical services directly to
the community
•
The Govt, of Gujarat has provided grants to SEWA-Rural in Gujarat for managing one
PHC and three CHCs. The NGO provides rural health, medical services and manages
the public health institutions in the same pattern as the Government. SEWA can accept
employees from the District Panchayat on deputation. It can also employ its own
personnel by following the recruitment resolution of either the Government or the District
Panchayat. However, the District Health Officer or the District Development Officer is a
member of the selection committee and the appointment is given in her/his presence. In
case SEWA does not wish to continue its services, the District Panchayat, Bharuch would
take over the management of the same.
2. The Municipal Corporation of Delhi and the Arpana Trust (a charitable organization registered
in India and in the United Kingdom have developed a partnership to provide comprehensive
health services to the urban poor in Delhi’s Molarbund resettlement colony. Arpana Trust runs a
health center primarily for women and children, in Molarbund through its health center ‘Arpana
Swasthya Kendra’. As contractual partners, Arpana Trust and MCD each has fixed
responsibilities and provides a share of resources as agreed in the partnership contract. The
Arpana Trust is responsible for organizing and implementing services in the project area, while
the MCD is responsible for monitoring the project. The MCD provides building, furniture,
medicines and equipment, while the Arpana Trust provides maintenance of the building, water
and electricity charges, management of staff and medicine.
7
3. Management of Primary Health Centers in Gumballi and Sugganahalli was contracted out by
the Government of Karnataka to Karuna Trust in 1996 to serve the tribal community in the hill y
areas. 90% of the cost is borne by the Govt, and 10% by the trust. Karuna Trust has full
responsibility for providing all personnel at the PHC and the Health Sub-centers within its
jurisdiction; maintenance of all the assets at the PHC and addition of any assets if required at the
PHC. There has been redeployment of the Govt, staff in the PHCs, however some do remain in
deputation on mutual consent. The agency ensures adequate stocks of essential drugs at all
times and supplies them free of cost to the patients. No patient is charged for diagnosis, drugs,
treatment or anything else except in accordance with the Government policy. The staff salaries
are shared between the Govt, and the Trust.
Gumballi district is considered a model PHC covering the entire gamut of primary health care preventive, promotive, curative and rehabilitative
Similarly in Orissa, PPPs are being implemented for safe abortion services and social marketing
of disposable delivery kits. Parivar Sewa Sanstha and Population Services International are
implementing the Sector Investment Plan in the state.
4. The Government of Tamil Nadu has initiated an Emergency Ambulance Services scheme in
Theni district of Tamil Nadu in order to reduce the maternal mortality rate in its rural area. The
major cause for the high MMR is anon-medical cause - the lack of adequate transport facilities to
carry pregnant women to health institutions for childbirth, especially in the tribal areas. This
scheme is part of the World Bank aided health system development project in Tamil Nadu. Seva
Nilayam has been selected as the potential non-governmental partner in the scheme. This
scheme is self-supporting through the collection of user charges. The Government supports the
scheme only by supplying the vehicles. Seva Nilayam recruits the drivers, train the staff, maintain
the vehicles, operate the program and report to the government. It bears the entire operating cost
of the project including communications, equipment and medicine, and publicizing the service in
the villages, particularly the telephone number of the ambulance service. However, the project is
not self-sustaining as the revenue collection is lesser than anticipated.
Seva Nilayam also operates another program in the Theni district called the Emergency Accident
Relief Center for which the government has also provided a vehicle.
5. The Urban Slum Health Care Project the Andhra Pradesh Ministry of Health and Family
Welfare contracts NGOs to manage health centers in the slums of Adilabad. The basic objectives
of the project are to increase the availability and utilization of health and family welfare services,
to build an effective referral system, to implement national health programs, and to increase
health awareness and better health-seeking behaviour among slum dwellers, thus reducing
morbidity and mortality among women and children. To serve 3 million people, the project has
established 192 Urban Health Centers. Five ‘Mahila Aarogya Sanghams’ (Women’s Wee-Being
Associations) were formed under each UHC, and along with the self-help groups and ICDS
workers mobilize the community and adopt Behaviour Change Communication strategies.
The NGOs are contracted to manage and maintain the UHCs, and based on their performance,
they are awarded with a UHC, or eliminated from the program. Additional District Magistrates and
Health Officers supervise the UHCs at district level and the Medical Officer is the nodal officer at
the municipality level. The District Committee approves all appointments made by the NGOs for
the UHC staff. The Govt, of Andhra Pradesh constructs buildings for the UHCs; provide honoraria
to the Project Coordinators of the UHCs, medical officers and other staff; train staff members; and
supply drugs, equipment and medical registers.
6 In recent examples, collaboration that has developed between Government of Arunachal
Pradesh, VHAI and Karuna Trust in managing significant number of PHCs may be seen at
Annexure IV.
8
C. Partnership between the Government and a private service provider
Several examples for the above partnership could be quoted from the Indian experience:
1. Partnership between the Department of Family Welfare and Private Service Providers:
•
•
•
•
•
•
•
•
•
2.
The DoFW has appointed one additional ANM on contractual basis in the remote sub
centers (which constitute 30% of all sub centers in C category districts in 8 states) to
ensure better emergency obstetric care under the RCH programme. Similarly 140 ANMs
could be appointed in Delhi for extending their services in the slum areas. The scheme
has been extended to the North Eastern states with effect from 1999-2000
Public Health/Staff nurses have been appointed on a contractual basis at PHCs/ CHCs
having adequate infrastructure for conducting deliveries.
In order to plug deficiencies in providing emergency obstetric care at FRU due to non
availability of anesthetist for surgical interventions, states have been permitted to engage
the anesthetist from the private sector on a payment of Rs. 1000 per case at the sub
district and CMC level.
With a view to supplement the regular arrangement, provision has been made for
engaging doctors trained in MTP as Safe Motherhood Consultant who will visit the PHC
(including CHCs in NE states) once a week or at least once in a fortnight on a fixed day
for performing MTP and other Maternal Health care services. These doctors will be paid
@Rs.5OO per day visit.
A scheme for reservation of sterilization beds in hospitals run by government, local
bodies and voluntary organizations was introduced in 1964 with view to provide
immediate facilities for tubectomy operations in hospitals. At present too, beds are
sanctioned to hospitals run by local bodies and voluntary organizations and grant-in-aid is
provided as per approved pattern of assistance.
The Haryana Urban RCH Model is being implemented in 19 urban slums and benefits 15
lakh beneficiaries. In this model, a private health practitioner (PHP) has been identified to
provide comprehensive primary health care service to a group of 1000-1500 targeted
beneficiaries. S/he provides services related to National Disease Control Programme,
contraception, immunization, ambulatory care. The PHP gets an incentive of Rs. 100 p.a.
per beneficiary by the Government. The model is envisioned to be self-sustaining by the
5th year.
A proposal has been submitted by PSS, Rajasthan to the GOI for establishing a
comprehensive RCH clinic in 3 districts, wherein PSS would provide services like
sterilization, MTP, spacing, ante/post natal care, immunization, RTI/STI. The cost to be
borne by the Govt, is Rs. 18 to 20 lakhs p.a. per clinic. With a view to ensure project
sustainability, the user fees is sought to be deposited in a bank account.
The Samaydan Scheme in Gujarat aims to ease the problem of vacancies of specialists
in health and medical services. About 125 honorary and part-time specialists have been
appointed in rural hospitals under the scheme and the removal of age-eligibility criteria for
appointment of doctors in government services is also being considered.
Under the Urban Health Care Project, the community base health volunteers in the urban
areas would roped in to provide primary health care in the urban slums of Gujarat. Their
activities would be monitored by CHC/PHC/PPU/Urban Family Welfare Center/Trust
Hospital and they would be paid a fixed monthly honorarium.
The Department of AYUSH envisages accreditation of organizations with the MoHFW for
research and development in order to be eligible for financial assistance under the
scheme of Extra Mural Research on ISM&H. The eligible organizations include R&D
organizations recognized by the Ministry of Science and Technology, Govt, of India; one
Government or semi-Government or autonomous R&D Institution under the Gol/State
Government/Union Territory; and one private R&D institutions registered under any
State/Central Act as Research Organization.
9
D. Partnership between the Government and a private sector and/or the non-profit sector
and/or a private service provider and/or multilateral agencies
1. The National Malaria Control Programme has involved the NGOs and private practitioners at
the district level for the distribution of medicated mosquito nets. (LOGISTICS)
2. Under the National Blindness Control Programme, District Blindness Control Societies have
been formulated, which are represented by the Government, non-government and private
sectors. The NGOs have been involved for providing a package of services
3. The National AIDS Control Programme has involved both the voluntary and private sector for
outreaching the target population through Targeted Interventions (WIDER COVERAGE)
4. The Revised National Tuberculosis Control Programme has involved the private practitioners
and the NGOs for the rapid expansion of the DOTS strategy. The non-inclusion of the private
providers had been one of the main reasons for the failure of the earlier programme. The private
medical practitioners serve as the first point of contact for more than two-thirds of TB
symptomatics.
The GOI has initiated a Public Private Mix (PPM) pilot project with technical assistance from
WHO in 14 sites across the country viz. Ahmedabad, Bangalore, Bhopal, Chandigarh, Chennai,
Delhi, Jaipur, Kolkata, Lucknow, Patna, Pune, Bhubaneshwar, Ranchi and Thiruvananthapuram.
The areas of collaboration with the NGOs include: community outreach; health education and
promotion; provision of DOTS and in-hospital care for TB disease; TB Unit Model; programme
planning, implementation, training and evaluation.
Presently, there are 550 NGOs and 200 Private Practitioners involved in RNTCP. Attempts are
also underway to involve the medical colleges in the programme.
5. The Rajiv Gandhi Super-specialty Hospital in Raichur Karnataka is a joint venture of the
Government of Karnataka and the Apollo hospitals Group, with financial support from OPEC
(Organization of Petroleum Exporting Countries). The basic reason for establishing the
partnership was to give super-specialty health care at low cost to the people Below Poverty Line.
The Govt, of Karnataka has provided the land, hospital building and staff quarters as well as
roads, power, water and infrastructure. Apollo provided fully qualified, experienced and
competent medical facilities for operating the hospital. The losses anticipated during the first three
years of operation were reimbursed by the Govt, to the Apollo hospital. From the fourth year, the
hospital could get a 30% of the net profit generated. When no net profit occurred, the Govt paid a
service charge (of no more than 3% of gross billing) to the Apollo Hospital.
Apollo is responsible for all medical, legal and statutory requirements. It pays all charges (water,
telephone, electricity, power, sewage, sanitation) to the concerned authorities and is liable for
penal recovery charges in case of default in payment within the prescribed periods. Apollo is also
responsible for maintenance of the hospital premises and buildings, and maintains a separate
account for funds generated by the hospital from fees for registration, tests and medical charges.
This account is audited by a Chartered Accountant engaged by Apollo with approval of the
Governing Council. Likewise, Apollo maintains separate monthly accounts for all materials used
by patients below the poverty line (including diagnostic services), which are submitted to the
Deputy Commissioner of Raichur for reimbursement. Accountability and responsibility for
outsourcing the support services remain with the Apollo.
The controlling authority of the Govt, of Karnataka is vested in its District Commissioner. A
Governing Council is established to review the performance of the hospital periodically (twice a
year), make recommendations to improve the administration and management and also resolve
any disputes that might arise. The ten-member council is chaired by the Karnataka Health
10
Minister and includes the Raichur District Collector, the Apollo CEO, the Principal Secretary, the
Health Secretary, the Finance Manager, the Hospital Operations Manager, Medical Directors and
local Members of the Legislative Assembly (as special invitees).
6. The Karuna Trust in collaboration with the National Health Insurance Company and the
Government of Karnataka has launched a community health insurance scheme in 2001. It covers
the Yelundur and Narasipuram Taluks. Underwritten by the UNDP, the Karuna Trust undertook
the project to improve access to and utilization of health services, to prevent impoverishment of
the rural poor due to hospitalization and health related issues, and to establish insurance
coverage for out-patient care by the people themselves. The scheme is fully subsidized for
Scheduled Castes and Scheduled Tribes who are below the poverty line and partially subsidized
for non-SC/ST BPL. Poor patients are identified by field workers and health workers who visit
door-to-door to make people aware of the scheme. ANMs and health workers visiting a village
collect its insurance premiums and deposit them in the bank.
The annual premium is Rs. 22, less than Rs.2 a month. If admitted to any government hospital for
treatment, an insured member gets Rs. 100 per day during hospitalization - Rs. 50 for bed
charges and medicine and Rs. 50 as compensation for loss of wages - up to a maximum of
Rs.2500 within a 25-day limit. Extra payment is possible for surgery. The insurance is valid for
one year. If members want to continue the coverage, they must renew their membership and pay
the full premium.
7. The Government of Karnataka, the Narayana Hrudalaya hospital in Bangalore and the Indian
Space Research Organization initiated an experimental tele-medicine project called ‘Karnataka
Integrated Tele-medicine and Tele-health Project’ (KITTH), which is an on-line health-care
initiatives in Karnataka. With connections by satellite, this project functions in the Coronary Care
Units of selected district hospitals that are linked with Narayana Hrudalaya hospital. Each CCU is
connected to the main hospital to facilitate investigation by specialists after ordinary doctors have
examined patients. If a patient requires an operation, s/he is referred to the main hospital in
Bangalore; otherwise s/e is admitted to a CCU for consultation and treatment.
Tele-medicine provides access to areas that are underserved or un-served. It improves access to
specialty care and reduces both time and cost for rural and semi-urban patients. Tele-medicine
improves the quality of health care through timely diagnosis and treatment of patients. The most
important aspect of tele-medicine is the digital convergence of medical records, charts, x-rays,
histopathology slides and medical procedures (including laboratory tests) conducted on patients.
8. The Yeshasvini Co-operative Farmer’s Healthcare Scheme is a health insurance scheme
targeted to benefit the poor. It was initiated by Narayana Hrudayalaya, super-specialty heart
hospital in Bangalore, and by the Department of Co-operatives of the Government of Karnataka.
The Government provides a quarter (Rs. 2.50) of the monthly premium paid by the members of
the Cooperative Societies, which is Rs. 10 per month. The incentive of getting treatment in a
private hospital with the Government paying half of the premium attracts more members to the
scheme. The cardholders could access free treatment in 160 hospitals located in all districts of
the state for any medical procedure costing upto Rs. 2 lakhs.
The premium is deposited in the account of a charitable trust, the regulatory body for
implementing the scheme. A Third Party Administrator - Family Health Plan Limited that is
licensed by Karnataka’s Insurance Regulatory and Development Authority. The FHPL has the
responsibility for administering and managing the scheme on a day-to-day basis. Recognized
hospitals have been admitted to the network throughout Karnataka, which are called as network
hospitals (NWH). These hospitals offer comprehensive packages for operations that are paid by
Yeshasvini. A Yeshasvini Farmers Health Care Trust is formed to ensure sustainability to the
scheme, which comprises of members of the State Government and the network hospitals. The
Trust monitors and controls the whole scheme, formulates policies, appointed the TPA and
addresses the grievances of the insured members or doctors.
11
Only the members of an agricultural cooperative society could join this scheme, and also all
members of a given cooperative society must become members of Yeashsvini. This ensures
increase in the enrollment rates. The Government, apart from the premium subsidy has provided
key access to the cooperatives. The Department of Cooperatives has provided an administrative
vehicle to popularize the scheme.
The major drawback of this scheme is that the poor farmers are not covered for all health related
issues but only for out-patient care and all expenses connected with surgery.
9. A Rogi Kalyan Samiti (RKS) was formed in Bhopal’s Jai Prakash Governement Hospital to
manage and maintain it with public cooperation. The RKS or Patient Welfare Committee or
Hospital Management Society is a registered society and the committee acts as trustees for the
hospitals responsible for proper functioning and management of the hospital. Its members are
from local PRIs, NGOs, local elected representatives and government officials. Participation of
the local staff with representatives of the loci population has been made essential to ensure
accountability. It functions as an NGO and not a government agency. It may utilize all government
assets and services to impose user charges. It may also raise funds additionally through
donations, loans from financial institutions, grants from government as well as other donor
agencies. The funds received are not deposited in the State exchequer, but are available to be
spent by the Executive Committee constituted by the RKS/HMS. Private organizations could be
contracted out for provision of the super specialty care at a rate fixed by the RKS/HMS.
At JP Hospital, RKS was formed due to lack of resources and other functional problems, which
acted as an impediment to timely, and quality health service delivery. Due to delay or no
disbursement of funds, creation of a hospital management society capable of generating
revenues became imperative. After the formation of RKS, the quality of services increased in
terms of 24-hour availability of doctors and medicine, diagnostic facilities, better infrastructure,
cleanliness, maintenance and timeliness of services. Through RKS, the hospital has also been
able to provide free services to patients below the poverty line.
10. A public/private DOTS model was established on a pilot basis in Hyderabad at Mahavir Trust
Hospital, which is a private non-profit hospital. This partnership also involves private service
providers like doctors and nursing homes. This new approach is known as PPM DOTS (Public
Private Mix DOTS). As there are virtually no government services in the area, the private sector is
a full substitute for the public sector. Individual private practitioners were involved in the DOTS
programme as they form the first point of contact for most of the TB patients both for quality
health care as well as convenience to refer to the private practitioners rather than the hospitals at
frequent intervals.
The Mahavir Trust Hospital acts as a coordinator and intermediary between the government and
private medical practitioners (PMPs). It also acts as a supervisor. The PMPs refer patients
suspected of having TB to the hospital or to any of the 30 specified neighborhood DOTS centers
operated by PMPs. The patients pay the fees to the PMPs. In addition to providing a referral
center for an hour every morning at their own expense, the doctor gains professional and
commercial benefits to their practice that far outweigh the loss of several patients who could
never afford proper treatment in any case. In turn the Mahavir TB clinic informs the private
practitioners about the progress of their patients throughout their treatment. The Mahavir Hospital
and the PMPs keep the records for the government. The government provides TB control policy,
training, drugs and laboratory supplies. Five outreach workers trace late or delinquent patients
and provide community mobilization.
All stakeholders gain an advantage through this partnership. The Mahavir Trust Hospital benefits
because the money spent on the DOTS service cures patients. The government benefits because
the DOTS medicine are properly used instead of being wasted or even contributing to the
development of drug resistant TB. The medicines are curing the patients and the spread of the
12
disease is being arrested. From tan economic point of view, the PMPs and nursing homes are
able to provide an effective treatment, which enhance their goodwill and affects their business as
a whole too.
The pilot project is aimed at attaining uniformity in the diagnosis, treatment and monitoring, wider
programme coverage; saving the patient’s time and expenditure by a good referral network.
11. Multilateral organizations like the World Bank and the European Commission have supported
the Sector Investment Programme in India and the Department of International Development
(DFID) in the area of health sector reforms in India.
12. In recent examples, the Chiranjeevi experiment of Govt of Gujarat may be seen at Annexure
IV.
CHALLENGES FACED IN THE OPERATIONALISATION: KEY CONCERNS
The existing evidence for PPP do not allow for easy generalizations. However it appears that
despite additional efficiencies, the objective of additional resources is not met, as State revenue
remains the bedrock of all services. The evidence also reveals great disparity in services and in
remuneration. As is evident the objectives of the initiatives have been to overcome some of the
deficiencies of the public sector health systems.
Donations, introduction of user fees, insurance schemes are methods to augment resources.
Contracting out is resorted to when health facilities are either underutilized or non functional while
contracting in is used to improve quality of services or improve accessibility to high technology
service or to improve efficiency. Contractual appointment of staff aims to reduce the negative
impact of vacant positions. Voucher schemes and community based health insurance etc are
invoked to reduce the adverse effects of health care costs on poor patients and improve equity in
health system. Mobile health schemes, involvement of CBOs, health cooperatives etc are models
in improving accessibility, both physical and to the health system. Some of the partnerships are
for a short duration while the other is longer. The thrusts of the partnerships also vary. Some
focus on service delivery, some to augment resources and infrastructure, some towards
organizational and systemic improvements while others are simply advocacy oriented.
Contracting is the predominant model for public private partnerships in India. Some
partnerships are simple contracts (like laundry, diet, cleaning etc) others are more complex
involving many stakeholders with their respective responsibilities. For example the Yeshaswani
scheme in Karnataka includes the State Department of Cooperatives, the Yeshaswani Trust with
its almost 200 private hospitals, a corporate Third Party Administrator and the beneficiaries with
the eligibility conditions.
It is seen that in most partnerships, the State Health Department is the principal partner with
rare stakeholder consultation. In most cases it signs contracts with very few cases of Hospital
Management Societies signing the contracts in a decentralized manner.
In terms of monetary value the contracts at Kolkottta’s Bagha Jatin General Hospital provided
inexpensive dietary services at the rate of Rs 27 per meal for about 30 patients a day and
cleaning service at Rs 24000/- per month. The most expensive partnership was the Rajiv Gandhi
Super Speciality Hospital in Raichur where the Government of Karnattaka has paid several
hundred million rupees to the partner as start up cost plus an assurance to cover future losses.
The above initiatives also show that more than 75% of the projects have been located in
backward areas of the states.
However true partnerships in sense of equality amongst partners, mutual commitment to
goals, shared decision making and risk taking are rare.
The case studies also bring to fore genuine concerns summarized in terms of absence of
representation of the beneficiary in the process, lack of effective governance mechanisms for
accountability, non transparent mechanisms, lack of appropriate monitoring and governance
systems and institutionalized management structures to handle the task
13
It is seen that the success or failures of the initiatives are as much dependant upon the above
issues as on the political environment, legal framework of the negotiation, the capabilities of the
partners, the risks and incentive each party incurs, funding and the payment mechanisms, cost
and price analysis prior to negotiation, standardization of norms, performance measurement and
monitoring and evaluations systems.
POTENTIAL AREAS FOR PARTNERSHIP
Different models of PPP are useful under different circumstances. The PPP lists have a
wide-ranging set of PPP options ranging from options for improved service delivery,
augmentation of resources and infrastructure, organizational and systemic improvement, to
advocacy.
However any mechanism of PPP must be based on an assessment of local needs and a
situation analysis. For example strengthening the public health structure would be a more viable
option in many of the remote corners of the North Eastern states where the presence of private
sector is negligible.
On a conceptual level, it is quite clear that the private sector is as much responsible for
the health of the nation, therefore all health establishments, must provide some critical services,
i.e. family welfare, accidents and trauma and emergencies within their geographical areas and
manage infectious diseases of epidemic proportions.
However no health system can work through only a network of tertiary care hospitals.
The remedies for most of the deficiencies of the health system largely fall within the ambit of
Primary Health Care - whether they are promoting, preventive or curative. Therefore at least in
the next five years the focus should be on augmentation of the primary health care services in
terms of focus on better service delivery options, including ancillary services like ambulance
services and radiology services.
However to fulfill the requirement of additional manpower in terms of requirement of 3
lakh nurses and 12,000 Specialist doctors under NRHM, it is essential to explore a range of
partnership options in terms of private sector support to nursing institutions and medical schools
and colleges to make available the human resources required for NRHM. There would also be
massive requirement of managerial capacities under NRHM, which may be obtained through
partnerships.
The potential areas may be as follows:
> Services, disease control and surveillance, diagnostics and medicines.
> Infrastructure
> Health manpower
> Behaviour change communication
> Capacity building including training and systems development.
> Managerial service and auxiliary activities of the health sector
In the initial phase caution should be exercised against expanding into too many sectors.
Government funding should not exceed an overall cap of 15% of the budget allocation.
Super specialty care is not the goal. The intention is to provide basic health care to all
citizens of this country so that they do not face distress and duress in meeting health care needs.
RECOMMMENDATIONS FOR A PRACTICAL AND COST EFFECTIVE MECHANISM
Framework For Regulation
As is evident Partnership mechanisms do not work without quality assurance and an
enabling environment. Government must ensure that providers are accredited, at least essential
standards are set and followed, guidelines and protocols for diagnosis and treatment are
developed and used, and providers are kept updated through continuing medical education.
System must monitor and correct such important aspects of quality as infection prevention, client
satisfaction and access to services. For enablement the government must understand the
14
1
advantages, disadvantages and requirements of partnership. They need to understand that
partnerships are based on common objectives, shared risks, shared investments and
participatory decision-making.
Since there is an element of contradiction in the objective of strengthening of the public
health system by the private sector in which the private sector apparently is the ultimate looser,
therefore it is essential that the framework for the whole process of partnership is not ad- hoc.
Equity, Quality and Regulation should underline the entire deliberation and apply not only to the
Private Sector but also to the Public Sector.
Primary goal of any health system should be assurance of health care professional
competence to the public. For a minimalist regulation system that may be feasible in the current
socio-political environment it is suggested that:
1.
Any Health Care Professional, practicing in any area / institution, should register with the
Primary Health Officer of the Area or the Institution as the case may be. For this purpose an
appropriate officer in the Primary Health Centres / Urban Health Centres may be identified as the
Primary Health Officer. Every Health Care Institution may be required to designate an officer as
the Institution’s Primary Health Officer. The Registers maintained by Primary Health Officers
should be accessible to public. The Register will also help Primary Health Centres and Public
Health Officials to manage public health emergencies and for epidemiological surveillance.
2.
Clinical Establishment Act, requiring registration of Health Care Institutions and Hospitals
with appropriate Health Authority. Clinics, Nursing Homes and Small Hospitals of less than 100
beds may register with Local Health Authority, to be designated for about 5 lakh population
(Revenue Division / Sub Division), larger hospitals may register with District Health Authorities
and Tertiary Referral Hospitals may register with concerned State Health Authority. The Act
should also provide for registration at the district level with the Zilla Parishad or the DHA
wherever capacities of PRIs are wanting and include redressal mechanism for health institutions
(Example diagnostic Centres) owned by a non-medical person.
The registers of professionals practicing in an area or within an institution should in the
public domain available for public use and scrutiny. This would eventually lead to setting up of a
national database on professionals practicing in different areas and institutions in different parts
of the country and will also help in the judicial process. Therefore it is important that Registration
should be in the Government domain and not with an autonomous body
The need for regulation should not only be for providers but also for training educators
and training facilities. There is also a need for a regulatory framework for the proposed Rural
Medical Practitioners as they would be key players in the primary health delivery systems.
Since managerial issues and governance capacities within the public health system are
key issues in determining the effectiveness of registration therefore, in the initial phase, self
registration should be encouraged followed by an interim accreditation mechanism developed
with the help of FOGSI/IMA before a fully e-governed registration system could be
institutionalized.
“Accreditation” as a voluntary process with set standards, provision for external review
etc. must also be supported and incentives for accreditation must be encouraged. The
accreditation initiatives in India at the National level (QCI, NABL) and at the State Level (AP,
Karnataka, Tamil Nadu, Kerela and Maharashtra) are progressive steps.
A range of Accreditation Systems ranging from compulsory accreditation, accreditation by
independent agencies, and facilitation of establishment of State Accreditation Councils to a blue
print developed by the Ministry of Health & Family Welfare may be explored. It is however
important to involve the stakeholders, build capacity, have different bodies at different levels, and
collect evidence base for the whole process. Accreditation should have synergy with Regulation.
15
The process of accreditation of Mother and Child Hospital specifying certain minimum
standards had already begun in Tamilnadu for the Janani Suraksha Yojana (JSY) Scheme.
However, in the process of accreditation there should be no fallback to the License Raj.
There should be a single window for registration/accreditation of health institutions.
Framework Of Partnership
It is a prerequisite to make the partnership a publicly driven process in order to improve
its legitimacy in the eyes of the common citizen. It is also important that there is clear articulation
of responsibility, an open process and meticulous detailing to avoid suspicions and
apprehensions in the minds of all. Therefore the power relations in the partnership also needed to
be understood.
There is a need for defining the specific elements of the partnership from both sides as
many a time the private provider feels that the Government itself does not undertake any
guarantee in the Partnership.
All PPPs should meet at least two basic criteria, namely (a) Value for Money and (b)
Clearly defined sharing of risks. There is need to develop skills within the government for
assessment of the Value for Money and Risk sharing characteristics of PPPs. One common
requirement for assessment of Value for Money proposition is existence of good comparators.
For example; NGO Management of PHCs uses current budgetary allocations of PHCs as a
comparator to make financial allocation. Similarly average out patient consultations or such other
therapeutic procedures, and public health activities in other PHCs can be used to assess the
performance of PHC under PPPs. CAG should be requested to develop specialised skills for
assessment of Value for Money and risk sharing characteristics of PPP projects. Auditing of
government expenditure through PPPs requirement would be different from traditional audit of
expenditure directly made by government departments. Unless the CAG develops capacity for
auditing of public expenditures through private partnerships, large scale expansion of PPPs
would be difficult.
Transparency, Accountability, Trust, measurable efficiency parameters and Pricing
remain vexatious issues in the partnership process.
The framework of partnership should also provide for the costing of services to ensure
that common citizens can get/buy cost effective services.
The governmental system of fixing rate is fraught with difficulties and it is better to
adopt public costing with moderation and states need to work out the cost effectiveness very
meticulously. It may be noted that no serious effort at costing of services and standard treatment
protocol has been attempted in the government domain. The National Commission on Macro
economics and health (NCMH) is the first attempt to document the cost of services in the public
sector. Attempts at costing under various PPP schemes like the Yeshaswani scheme of
Karnattaka and the Chiranjeevi scheme in Gujrat have been attempted. However more work is
required to be done in this area and the initiative should be taken by the Ministry and the States.
(Examples of a few cost effective options are at Annexure 1)
Decentralization should be the key in dealing with partnerships as centralized models
suffer from failings enumerated in the aforesaid sections. The challenge under the NRHM is to
operationalise partnerships at the District level. Therefore there is also a requirement for district
level skills and managerial capacity for making the process accountable, affordable and
accessible to common citizens.
The resource support and technical assistance for the PPP mechanism may come from
the National Health Systems Resource Centre (NHSRC), State Health Systems Resource Centre
16
(SHSRC) and the District Health Systems Resource Centre (DHSRC) being set up under NRHM
at the National, State and the District level respectively.
The National Institute of Health & Family Welfare (NIHFW) can be the nodal agency for
guiding PPP Policy at the National level. A PPP Cell at the NIHFW can also function as the
Documentation and dissemination Centre for PPP initiatives in the States. Resource support may
be provided under NRHM to fund this Cell. These Cells may be replicated in the States and the
Districts within the overall umbrella of the State Health Society and District Health Society under
NRHM.
District level Health Resource Centres, can help in developing transparency in PPP and
provide the much needed managerial capacity to manage processes like Accreditation and
Standards.
Public Private Partnership needs to be mutually beneficial to both the parties so that
there is encouragement of enterprises and element of pragmatism. It is important that the health
professionals also earn in the process to sustain the partnership. However, the earning should
be commensurate to the health services provided specially to the poor. This is possible through
the volumes of patients, which the private sector would be getting from the public sector.
There is a need for further documentation of the ongoing experiments in PPP and
evaluation of their impact. The evaluation mechanism should highlight the issues of access,
utilization, sustainability, cost effectiveness and pricing, equity, transparency, audit etc.
Models For Partnership
It is essential to appreciate the diversity in terms of regional variations in the health status
across the country. Therefore, generic models of existing PPP practices like contracting in,
contracting out, social marketing, and social franchising may be modified to suit local variations.
The assumption here is that a homogeneous prescription would not work and therefore the
challenge is to develop the nitty-gritty of a framework allowing for diversity of models esp. at the
District Level.
Public-Private-Partnership Models (Details at Annexure 2)
• Contracting:
Contracting out
Contracting-in
• Franchising:
Partial franchising
Full franchising
Branded clinics
• Social marketing
• Joint ventures
• Voucher schemes
•
Hospital autonomy
•
Partnership with corporate sector/ industrial houses
•
Involving professional associations
•
Build, operate and transfer
• Donation & philanthropic contributions
•
Involvement of social groups
•
Partnership with co-operative societies
•
Partnership for capacity building
•
Partnership with non-profit community-based organizations
• Running mobile health units
• Community based health insurance
PRINCIPLES OF PPP
17
Although the approaches are different for each typology to resolve the health crisis
currently in hand, there are certain common underlying principles guiding each of such
partnerships, which are enumerated below:
1. Setting up of common goals and objectives, which are committed by all the partners.
2. Outcome based planning
3. Joint decision-making process
4. Creation of a social good by improving the health situation of the poor and underserved as well
as standardization and uniformity of quality health service delivery
5. Accountability and responsibility set out vividly for each partner
6. Sharing of costs and resources are done on the basis of equity. The same principle is followed
for sharing risk and rewards. Central to any successful public-private partnership initiative is the
identification of risk associated with each component of the project and the allocation of that risk
factor to the public sector, the private sector or perhaps a sharing by both. Thus, the desired
balance to ensure best value (for money) is based on an allocation of risk factors to the
participants who are best able to manage those risks and thus minimize costs while improving
performance.
7. Regular meetings among the partners to discuss issues at hand and planning and coordinating
for the future
8. A clear understanding of the strengths and weaknesses of the partners among themselves is
essential to understand their roles and responsibilities clearly
9. The monitoring mechanisms are made sound in order to address the diversity of the
partnerships
10. Financial sustainability is an all-pervading factor, which forms the backbone of all
partnerships. There has to a regular flow of funds in order to meet the personnel and operating
costs. Some programs have become self-sustainable only by involvement of the people. Such
schemes do not require regular funds from the Government
11. Partnerships could be full substitution of the provision of health services, or managing the
operations or monitoring or provision of infrastructure (equipments, manpower, etc.)
12. Any vested interest in such structures could destroy the base, and lead to the failure of the
whole institution. Thus, a high level of trust and confidence is required in all the PPP initiatives.
13. Effective communications are key to the public's understanding of public-private partnerships.
Communications are required to be planned and carried out as an integral part of the
management process for any project. It involves timely sharing of information, accurate and
consistent messages conveyed to key audiences, realistic messages from trusted sources that
set realistic expectations.
14. PPP involves a long term relationship between the public sector and the private sector. While
the collaboration between the two may take various forms like buyer seller relationship, donor
recipient relationship, the most stable partnership is in the form of “contract” binding on both the
parties. The contract mirrors the basic objective of the programme/project, the tenure of
agreement, the funding pattern and of sharing of risk and responsibilities. The need to define the
contract very precisely, therefore, becomes paramount under PPP.
Project/Programmes under PPP may, however, broadly be classified under three heads
namely (i) service contract (ii) operations & maintenance (management) contract and (iii) capital
project, with operations & maintenance contract.
Selection of Service Provider
Transparency in ‘selection’ is an essential feature of PPP. Selection of the developer or the
service provider may be done in any of the following three ways.
(i) Competitive Bidding
This involves it well publicized and a well designed bid process to ascertain financial,
technical and managerial capabilities of the service provider or the developer. Either of the two
18
formats for bidding, namely single round sealed bid auction or multiple round open entry
(ascending) bid auction could be adopted. The appropriate biding process depends on the nature
of the valuation that the bidders place on the concession, that is, on the right to do the job.
In some cases the valuation of the project depends on factors that are within the bidder’s
control, such as construction and maintenance cost of a building or a road. These are also
known as ‘private value items’. In other cases, the valuation does not depend just on the bidders
own assessment, but also on certain unknown factors that need to be anticipated. These
unknown factors are common to all bidders and each bidder may update his/her own assessment
based on the assessment of other bidders. These are know as ‘common value items’ and include
factors such as the size of market, willingness to pay of consumers and future behaviour of
regulatory etc.
For private value items, a single round auction is appropriate since bidders do not need
to learn from the revelation of information of other bidders and a sealed bid auction is preferable
since that has the least potential for collusion. Concessions with common value characteristics
on the other hand, are best awarded through multiple round bids since this facilitates the process
of value discovery by bidders, allowing bidders to observe and respond to quotations/prices as
they emerge. Multiple round bid can also be sealed bid but there is opportunity to rebid after the
bids are opened. Moreover, wherever the bid process is characterized by a two stage process
involving for instance, mega infrastructure projects, the bidders are required to obtain from their
prospective lenders the financial terms, expectations regarding state support as well as their
comments on the concession agreement etc.
The final selection of the developer/service provider depends upon one or a combination
of the following (a) lowest capital cost of the prOoject (b) lowest operation and maintenance cost
(d) lowest bid in terms of the present value of user fees (c) lowest present value of payment from
government (d) highest equity premium (c) highest upfront fee (f) highest revenue share to the
Government and or 9g) shortest concession period.
Under situations of only a sole bid being received, the authorities have the choice of
either accepting or rejecting the sole bid. In the case of rejecting the sole bid, or when no bid is
received, the project/programme proposal itsSelf may be modified and the bid process restarted.
Alternatively the selection of the developer/service provider is done through competitive
negotiation with the private sector participants.
(ii) Swiss Challenge Approach
The Swiss Challenge approach refers to suo-moto proposals being received from the
private participant by the government. The private sector thus provides (a) all details regarding
its technical financial and managerial capabilities (b) all details regarding technical, financial and
commercial viability of the project/programme (c) all details regarding expectation of government
support/concessions.
The government may examine the proposal and if the proposal belongs to the declared
policy of priorities, then it may invite competing counter proposals from others (in the spirit of
‘Swiss Challenge’ approach) giving adequate notice. In the event of a better proposal being
received, the original proponent is given the opportunity to modify the original proposal. Finally
the better of the two is awarded the project/programme for execution.
(iii) Competitive Negotiation
Competitive negotiation (direct or indirect) is considered a variant of competitive bidding. The
Government thus specifies the service objective and invites proposals through advertisement.
The government then negotiates/finalise the contract with the selected bidders.
19
The government agency (or the local authority) may select the service provider/developer
through competitive negotiation in the following cases:
a)
b)
c)
d)
e)
Social sector projects and programmes involving VOs/NGOs/Local Community.
Project involving proprietary technology or a franchise;
Linkage project related to a mega project or a major activity.
Projects and programmes which failed to solicit any response to a bidding process.
Su-moto proposal from private participants.
Negotiation may, however, be ‘simple’ (direct) or ‘complex’ (indirect). In the second case,
the government negotiates through a master contractor/mother, NGO. In other words, contracts
for (public) services are contracted out and the master contractor handles all dealings with subcontractors/franchises. While the government reviews the works of the master contractor through
its monitoring (officials) who may visit the site of programme implementation and meet the
beneficiaries, the master contractor may monitor the programme (run by sub-contractors) through
collecting
information
from
the
beneficiaries
selected
randomly,
based
on
questionnaires/interviews.
Advantage of Master Contractor
Some of the advantages mentioned about master contracting are: (a) government has
administrative convenience, and better control in dealing with less number of service providers (b)
funds can be raised from other public and private sources, other than the government (c) decision
can be taken more quickly despite political pressures and (d) training programmes can be
organised for the sub-contractors/service provider/vendors by the master contractor more
innovatively.
However, master contract is not always relevant and negotiation vis-a-vis the contract
ought to be done directly with the community/beneficiaries as for instance, in the case of wild life
protection with the residents living in the vicinity of the forest. Competitive negotiations are,
however, less transparent than competitive bidding. With a view to ensure fairness nonetheless,
it is recommended that the government auditor may audit such contracts.
16. Payment mechanism: Payment to the private sector could take the form of (a) contractual
payments (b) grants-in-aid and 9c) right to levy user charges for the asset created/leased in.
Contractual payment may be in the form of advance payment, progress payment, final payment
annuities and guarantees for receivable etc. Annuities, in turn could be with respect to recovering
the fixed cost or for recovering both variable cost and the fixed cost of the project. In the form
case, both the government and the private partner share the risk of running the project.
Grant-in-aid in turn can take different forms such as a block grant, capital grant matching
grant, institutional support etc. Lease agreement license similarly may allow the concessionaire
to recover the cost of construction/operation & maintenance through levying user charges.
Moreover, in the case of lease agreement, the asset reverts to the government after the expiry of
the contract. The agreement ought to also provide for the condition of asset that would be
returned at the end of the contract.
17. Monitoring & Evaluation: It is quite often, thought that the job is over with the signing/finalizing
the contract. Payments have to be, however, linked to performance, which in term requires
monitoring. Performance measurement can be done with respect to measuring efficiency or
measuring effectiveness. While measurement of efficiency entails comparing the unit cost of
providing the service from amongst the various alternatives, measurement of effectivenSess
involves comparing the desired outcomes from amongst the various alternatives.
20
Monitoring may be done in either of the following ways (i) by government departments
authorized to do so, based on a standardized scale (ii) by independent agencies/regulators based
on a standardized scale (iii) by the department or independent agencies, based on the simple
criteria of pass and fail by the department or independent agencies, based on the feed back
received from the beneficiaries.
Involvement of third party/independent agencies for monitoring appears to be preferable
as they leave the government hassle free over the project and minimize government control. A
certain percentage of the cost of the project needs to be, therefore, earmarked for contract
management. The government and the developer/service provider could mutually decide the
third party. The third party involvement could be further supplemented with provisions for
adjudication by the highest judiciary.
The following would be useful parameters in monitoring and evaluation of the initiatives:
> Profile of implementing agency: history, organizational structure, management board,
business, service provided
> Procedures followed in signing the partnership- decision making process,
competitiveness and transparency in selection process, criteria for selection and time
taken
> Cope and coverage of services under agreement
> Eligibility conditions for the private agency-minimum investment, proper experience
> Specific clauses in the MOU-maximum duration of the contract, pricing and service
specification, billing and payment mechanism, managerial flexibility, supervision and
monitoring, quality control, employment service conditions of the staff, physical
infrastructure support, subsidies and incentives, penalties and fines, exit clause,
grievance redressal system
> Performance evaluation, renewal of contract
> Public health objective clause- specific services and subsidies to poor, women and
children
> Feedback of stakeholders-state and central bureaucrats, public health facility managers,
private agency managers, beneficiaries, staff in both public agency and private agency,
community leaders
Conclusion
The Government plays a predominant role in any PPP. Hence it has to follow certain
successful strategies in order to become a better partner. The key elements of a successful PPP
are as follows:
1. The Government should look at the long-term value in a partnership
2. Selection of the right partner becomes imperative for the government to achieve tangible
outputs and create the ‘best value’. A partner's experience in the specific area of partnership
being considered is an important factor in identifying the right partner.
3. By aligning the stakeholders’ interests, the Government could endeavor better value creation
4. The Government could a adopt a more strategic approach by stepping back from the day to
day management of public enterprises, and instead focusing on the drivers of long term value,
setting targets and encouraging alliances and partnerships with the private sector.
5. The Government should introduce greater transparency. Greater openness about the financial
performance and service delivery of public enterprises will be a useful discipline on managers
within those organizations. Focusing on a few strategic targets will be a start.
6. The Government could introduce greater shareholder expertise by ensuring an appropriate mix
of skills and experience among the partners to help carry out the health objectives more
efficiently.
7. However, if PPPs are genuinely going to deliver better quality services, it is vital that they are
designed with the focus on outputs and performance. The private sector partner or partners need
to be clear about what is expected from them and the implications if they fail to deliver.
8. The Government must recognize that it has a continuing role in the public service element of
essential services. In some cases, this may mean retaining some elements of service delivery in
21
the public sector. Therefore it becomes critical to decide on retaining the control over certain
services, rather than contracting them.
9. The Government could adopt the following approaches to deliver partnerships:
(a) Undertaking appropriate partnerships by understanding what works best in a given situation,
the circumstances in which they are to be implemented and the objectives which they are
intended to serve
(b) Creating innovative and imaginative partnerships and creating new ways of working - learning
by doing - is key, particularly where there is no existing best practice
(c) Designing a holistic approach PPPs by joined-up thinking, reflecting the needs of customers,
potential partners and providers, as well as joined-up Government initiatives rather than the
narrowing the objectives to the departmental territory.
The performance of any PPP in the health sector could be evaluated based on the following
building blocks:
1. Beneficence or public health gains
2. Non-malfeasance or not leading to ill health
3. Autonomy enjoyed by each partner
4. Shared decision-making
5. Equity or distribution of benefits to those most in need
However it may be reiterated that the private partnerships are not sufficient to resolve the
dilemma of inadequate health care for the people. The focus of Public policy in the context of
the11th Five Year Plan should be the flagship march for strengthening the public health sector.
22
Annexure-1
MOST PRACTICAL & COST EFFECTIVE MODE OF PPP FOR IMPROVEMENT IN
HEALTH SERVICES DELIVERY
PROBLEM AREAS
AT VARIOUS
LEVELS IN HEALTH
SERVICES
DELIVERY
TYPE OF SUGGESTED
PARTNERSHIP
SHORTAGE/
ABSENCE OF
SPECIALISTS
APPOINTING
SPECIALISTS ON
CONTRACT BASIS ON
WEEK ENDS OR SO.
ABSENCE/POOR
QUALITY OF RADIO
DIAGNOSTIC
MACHINERY
INSTALLATION OF
RADIO DIAGNOSTIC
MACHINERY (CT,USG,XRAY) BY PRIVATE
SECTOR ON CONTRACT
IN BASIS IN THE
PREMISES OF THE
HOSPITAL
■ Lj
WORKING MODELS
HOSPITAL SET-UP
GOVT OF GUJARAT
IMPLEMENTED THE
PARTNERSHIP IN
SEP 2002 IN
NARMADA DISTT.
AND LATER
EXTENDED TO
RAJKOT DISTRICT
COST EFFECTIVITY
REMARKS
FUND POOLING FROM
UNUSED BUDGET DUE TO
VACANT SPECIALISTS
POSITION TO USE FOR
CONTRACTING PRIVATE
PRACTITIONERS
PARTNERSHIP IS
ON
CONTRACT
BASIS
AND
RS
500(LATER
EXTENDED TO RS.
1000 PER VISIT)
PER VISIT TWICE A
WEEK
IS
PAID.
EVALUATION
SHOWED
THAT
ARRANGEMENTS
ENSURED ACCESS
TO
SPECIALIST
SERVICES
AT
HOSPITALS.
HOWEVER,
PER
DAY HONORARIUM
SHOULD BE KEPT
EQUIVALENT
TO
ONE DAY SALARY
OF
SPECIALIST
WITH
CONVEYANCE
CHARGES OF RS
500/SERVICES ROUND THE
CT MACHINES HAVE
TERMS
&
RFFN
I FR
BEEN INSTAI
INSTALLED
CLOCK AT REDUCED
CONDITIONS
AND ARE BEING RUN PRICES, FREE SERVICE FOR STATE THAT FREE
BY PRIVATE BPL PATIENTS
—---------------------& SENIOR
SERVICES SHOULD
AGENCIES IN 7 GOVT
CITIZENS, A FIXED NO. OF
BE GIVEN TO AT
LEAST
35
HOSPITALS IN WEST
INVESTIGATIONS/MONTH
BENGAL.
/HOSPITAL AFTER WHICH
rai
PATIENTS/iixni o/
THEY CAN CARRY AS MUCH
HOSPITAL AND TO
AS THEY WISH BUT THEY
‘ — MORE
NOT
-------- ------THAN
WILL HAVE TO PAY
615
CASES/
COMMISSION PER PATIENT
HOSPITAL/ MONTH
AT
APPROVED
GOVT RATES. 25%
COMMISSION
AFTER
THE
SPECIFIED CASES
TO BE PAID TO
STATE
GOVT.
MODEL RESULTED
IN OVERALL COST
REDUCTION
ACROSS THE CITY.
PATIENTS
FEEDBACK
IS
MUST
FOR
COMPLIANCE
OF
CONDITIONS
23
ABSENCE OF 24x7
LAB SERVICES
ON THE BASIS OF
CONTRACTING IN
PARTNERSHIP WITH
THE PRIVATE SECTOR
PARTNERSHIP
BETWEEN M/S
THUKRAL
DIAGNOSTICS
CENTRE LUCKNOW &
BMC AND PG
ALIGUNJ
IMPLEMENTED IN
MARCH 2003
NO EXTRA COST ON
STRETCHING THE LAB
SERVICES TO ROUND THE
CLOCK, FREE SERVICES
FOR BPL PATIENTS WHOSE
FEES CAN BE REIMBURSED
FROM THE HOSPITAL
WELFARE COMMITTEE
IN 1994 IN SWEDEN A
FOR PROFIT
LABORATORY
CALLED
MEDANALYZE WAS
AWARDED A
CONTRACT TO
HANDLE LAB TESTS
FOR PRIMARY CARE
PHYSICIAN IN A
DISTRICT OF
STOCKHOLM
COUNTY.
DIFFICULTY IN
ACCESS TO
SUPER-SPECIALIST
HEALTH SERVICES
IN REMOTE AND
HILLY AREAS
SETTING THE TELE
MEDICINE & TELE
HEALTH SYSTEM ON
CONTRACTING OUT
BASIS WITH THE
PRIVATE SECTOR
KARNATAKA
INTEGRATED TELE
MEDICINE-AND TELE
HEALTH PROJECT, IN
KARNATAKA DISTT
HOSPITAL,
NARAYANA
HRUDAYALYA
BANGALORE IN
COLLABORATION
WITH
REDUCED TRAVEL AND
ELIMINATION OF
UNNECESSARY PATIENT
TRANSFER, LOW CAPITAL
INVESTMENT FOR
ESTABLISHING A CARE
PRESENCE. TRAINING AND
RE- TRAINING AT THE
LEAST COST POSSIBLE
IN
CASE
OF
SMALLER
UNITS,
GOOD AND BAD
LOCATIONS
SHOULD
BE
AWARDED
TOGETHER
TO
COMPENSATE FOR
POSSIBLE LOSSES
SELECTED
DIAGNOSTIC
CENTRE PROVIDES
3 DIFFERENT
PACKAGES AT
REASONABLE
COST FOR
EMERGENCY
INVESTIGATIONS.
THE
ARRANGEMENT
ENSURES THE
PREGNANT
WOMEN AND
CHILDREN HAVE
THE ROUND THE
CLOCK ACCESS TO
LAB
INVESTIGATIONS
AT AN
AFFORDABLE
COST
THE STOCKHOLM
MODEL FAILED AS
THE COMPANY
WAS UNABLE TO
HANDLE THE
LARGE VOLUME OF
SAMPLES AND
BEGAN
MISHANDLING
SPECIMENS AND
EVEN
FABRICATING
RESULTS AS A
MEAN OF COPING.
EXIT POLICY MAY
BE CONSIDERED.
ONLY ACCREDITED
AND TRUSTED
LABS IN HEALTH
SECTOR SHOULD
BE CONSIDERED.
GOVT MAY
EXEMPT RENT,
WATER CHARGES
ETC FOR REMOTE
AREAS
THE 27
cSSX.
_________ .
ARE THE LARGEST
E-HEALTH
CENTERS IN THE
WORLD.
SO FAR 16000
HEART PATIENTS
HAVE BEEN
TREATED VIA AN
24
INDIAN SPACE
RESEARCH
ORGANIZATION.
OPERATIONAL SINCE
2002.
LOW AVAILABILITY
OF DOCTORS AND
MEDICAL
SERVICES
PARTNERSHIP WITH
THE CORPORATE/ BOT
FOR MEDICAL/ DENTAL
EDUCATION &
SERVICES
VARIOUS PRIVATE
MEDICAL/ DENTAL
COLLEGES ACROSS
THE INDIA.
NON/LOW
AVAILABILITY
OF MEDICINES
& SURGICAL
ITEMS
PARTNERSHIP OF
...... ..........
SOCIAL
MARKETING
TYPE CAN PROVIDE
CHEAPER MEDICINES &
SURGICALSIN
HOSPITAL PREMISES
LIFE LINE FLUID
DRUG STORE IN
SAWAI MAN
SINGH(SMS)
HOSPITAL, JAIPUR,
RAJASTHAN
STARTED IN 1996
‘E-WAY’.
GOVT MAY OFFER
TAX INCENTIVE OR
SOME OTHER
RELIEF IN LIEU OF
WORKING IN
REMOTE AREAS.
PENALTY CLAUSE
FOR NON
FUNCTIONING OF
FACILITY.
FACILITY CREATED
MAY ALSO BE
OPEN TO OTHER
PYT
PRACTITIONERS IN
SURPLUS TIME
NO EXTRA BURDEN IN
POLICY FOR
CORPORATE AND NO
PRIVATE SECTOR
PARTICIPATION IN
RUNNING COST IN BOT
MEDICAL/ DENTAL
EDUCATION SEEKS
TO ATTRACT
PRIVATE SECTOR
TO SET UP
COLLEGES IN THE
STATE. CRITERIA
IS LAID DOWN BY
THE STATE GOVT,
MCI & DCI. FINAL
DECISION IS
BASED ON THE
AVAILABILITY OF
LAND WITH THE
ORGANIZATION,
AVAILABILITY OF
HOSPITAL HAVING
MINIMUM 300 BEDS
FOR MEDICAL
COLLEGE
EXISTING
EXPERIENCE
FAILED IN DELHI.
GOVT MAY
PURCHASE
SERVICE FOR
POOR/NHPS ON
PREDETERMINED
RATES. HOWEVER,
GOVT MAY DECIDE
THAT NEW
PHCS/CHCS WILL
BE OPENED BY
PYT PLAYERS AND
GOVT WILL BY
SERVICES ON
YESHASVINI
MODEL
WITH NO EXTRA COST
THROUGH OPEN
STATE GOVERNMENT CAN
TENDER,RMRS
PROVIDE STANDARD STUFF
INVITE BIDS FROM
TO THE PATIENTS AT
SUPPLIERS TO
PROCURE
REASONABLE PRICE
ROUND THE CLOCK
MEDICINES THAT
LLFS SELLS TO ;
_________________
25
LACK OF
AMBULANCE/
TRANSPORT
SERVICES
PARTNERSHIP WITH
NGOS/CBO,USER
CHARGES/KM SCHEME
EMERGENCY
AMBULANCE
SERVICES, THENI
DISTRICT, TAMIL
NADU,
PARTNERSHIP IS
OPERATIONAL SINCE
2002.
AMBULANCE/TRANSPORT
SERVICES CAN BE
PROVIDED WITH NO EXTRA
EXPENDITURE ON
PURCHASING/
MAINTENANCE OF THE
VANS
LOW
SANITATION
AND LAUNDRY
STANDARDS
CONTRACTING
OUT/NGO PARTNERSHIP
GOVERNMENT OF
UTTARANCHAL HAS
HANDED OVER
LAUNDRY SERVICES
IN 9 BIG HOSPITALS
TO PRIVATE
AGENCIES IN
DECEMBER 2001
WHILE THOSE IN
DOON HOSPITAL
WERE HANDED
OVER IN FEB 2003
IMPROVED SANITATION AND
LAUNDRY
SMS PATIENTS AT
THE
PROCUREMENT
PRICES. RMRS
DECIDES THE
PERIOD OF THE
CONTRACT, WHICH
IS RENEWABLE ON
THE BASIS:OF
GO.ODPERFORMANCE.
WITH FIXED
SALARY AND A
ONE-PERCENT
COMMISSION ON
ALL SALES. THE
CONTRACTOR
APPOINTS AND
MANAGES STAFF
FROM THE :
RECEIPTS.
WILL BE
SUCCESSFUL
WHERE HIGHER
VOLUME OF SALE
EXIST. SMALLER
HEALTH UNITS
MAY ALSO BE
TAGGED WITH
BIGGER ONE IN
CONTRACT
TOTAL COST OF
THE PROJECT IS
6,50,000. RS. 5 PER
KM AS USER FEE.
FREE SERVICES
TO 10%
CASES,(BPL
PATIENTS).
MEMBERS OF
WOMEN’S SELF
HELP GROUP GET
10% CONCESSION.
THIS TYPE OF
INITIATIVES WILL
BE SUCCESSFUL
IF LARGE NUMBER
OF AMBULANCES
ARE CONTRACTED
WITH LEAST IDLE
TIME AND RATE IS
SUBJECT TO
REVISION WHEN
HIKED BY GOVT
THESE AGENCIES
HAVE BEEN
SELECTED ON THE
BASIS OF THE
COMPETITIVE
BIDDING.
MANPOWER;
CONSUMABLES,
EQUIPMENT AND
SALARY TO’
EMPLOYEE
26
DIETARY
SERVICES
CONTACTING IN WITH
PRIVATE CATERERS ON
COMPETITIVE BIDDING
BASIS
ALONG WITH THE
LAUNDRY/
SANITATION
SERVICES THE
GOVT. OF
UTTRANCHAL
HANDED OVER THE
DIETARY SERVICES
AS WELL IN THE FOR
MENTIONED
HOSPITALS
HYGIENIC AND NUTRITIOUS
FOOD WITHOUT EXTRA
BURDEN ON
INFRASTRUCTURE
HEALTH
INSURANCE
COVERAGE TO
THE STATE
POPULATION .
COMMUNITY BASED
HEALTH INSURANCE
ALSO CALLED SELF
FUNDED HEALTH
INSURANCE SCHEME.
HOWEVER THE SCHEME
IS NOT FULLY SELF
FUNDED BECAUSE IT
REQUIRES
GOVERNMENT
CONTRIBUTION
YESHASVINI-COOPERATIVE
FARMER'S HEALTH
CARE, KARNATAKA.
PARTNERSHIP
BETWEEN NARAYAN
HRUDAYLAYA
BANGALORE &
APOLLO HOSPITALS
HYDERABAD, TRUST
WAS LAUNCHED IN
2002
PROVIDE SURGICAL CARE
THROUGH LOW PREMIUM
HEALTH INSURANCE.
COVER NEARLY 1600 TYPES
OF SURGERIES. FREE OUT
PATIENT CONSULTATION.
MEDICAL AND DIAGNOSTIC
INVESTIGATIONS AT
NOMINAL RATES. SCHEME
COVERS EVEN
PREEXISTING ILLNESSES.
SHOULD BE
CAREFULLY
DRAFTED IN
AGREEMENT
OTHERWISE
SITUATION WILL
GET WORST__
THE SELECTION
OF THE PRIVATE
PARTNER WAS ON
THE BASIS OF THE
COMPETITIVE
BIDDING BY THE
HOSPITAL
AUTHORITY.
POOLING OF
ANCILLARY
SERVICES WILL
RESULT INTO
BETTER PROFIT TO
CONTRACTOR.
STRICT
CONDITIONS
ABOUT
COMPETENCE OF
CONTRACTOR AND
JOB TO BE DONE
IS NEEDED
1,600 DIFFERENT
SURGERIES
COSTING UP TO A
MAXIMUM OF RS.
200.000.MEDICAL
TREATMENT NOT
LEADING TO
SURGERY IS NOT
COVERED. GOVT.
OF KARNATAKA
ORIGINALLY
CONTRIBUTED 50%
OF MONTHLY
PREMIUM FOR
EACH MEMBER
NOW ONLY A
CONSOLIDATED
AMOUNT (OF RS.
3.5 MILLION IN THE
SECOND YEAR
AND 1.5 MILLION IN
THE THIRD YEAR).
FHPL IS PAID 4%
OR AROUND RS.
5.9 MILLION AS
THEIR FEE.
COMMITTED GOVT
CONTRIBUTION ON
LONG TERM BASIS
AND TIMELY \
COLLECTION OF
CONTRIBUTION IS
MUST. RATHER
CREATING NEW
HOSPITALS, GOVT
MAY ENCOURAGE
SUCH SCHEMES
ON LONG TERM
BASIS
AT CHCZ PHC LEVEL
27
IMPROPER
MANAGEMENT
POOR
OUTREACH
AND
REFERRAL
SERVICES FOR
SLUM
POPULATION.
CONTRACTING OUT
WITH THE PRIVATE
SECTOR
MANAGEMENT OF
PRIMARY HEALTH
CENTERS. KARUNA
TRUST, KARNATKA A
NON PROFIT NGO,
FROM 1996 ON TRIAL
BASIS , BUT BASED
ON FORMAL POLICY
DECISION, SINCE
2002
IMPROVED MANAGEMENT :
WITH THE SAME/LOW
BUDGET
CONTRACTING OUT TO
PRIVATE
ORGANIZATIONS
AR PANA SWASTHYA
KENDRA
MOLARBUND, DELHI,
IN PARTNERSHIP
WITH MCD.
PERFORMANCE
MEASURES ARE SET
FOR THE TRUST,
INITIAL CONTRACT IS
FOR 5 YEARS.
DISTRIBUTING THE BASIC
HEALTH PRODUCTS SUCH
AS CONTRACEPTIVES, ORS,
CLEAN DELIVERY KITS TO
THE SLUM DWELLERS THRU
EXISTING COMMERCIAL
NETWORK FUNDS POOLED
FROM RS. 10 FOR OPD
CARDS INCLUDING
MEDICINES FOR 3 DAYS, RS.
50 TO 100 FOR EMERGENCY
AMBULANCE SERVICES.
GOVT; PROVIDES
PHC PREMISES,
INITIAL
EQUIPMENTS AND
SUPPLIES, AND
75% TO 90%
SALARIES.
STAFFING BY THE
NGO,- RS. 25000
PER ANNUM AS
CONTINGENCY.
RS. 75000 PER
ANNUM FOR
DRUGS/SUPPLIES.
FREE HEALTH
CARE TO ALL
PATIENTS.
SELECTION OF
WORKERS
SHOULD BE. THE
PREROGATIVE OF
NGO., GOOD
WORKING AND
POOR WORKING
FACILITIES
SHOULD BE
JOINTLY HANDED
OVER. INCREASE
IN SALARY OVER
TIME MAY BE KEPT
IN MIND.
APPRAISAL BY
THIRD PART IS
MUST. GOOD
FINANCIAL MGT IS
KEY TO SUCCESS
PERSONALITY
DRIVEN PROJECT.
LACK OF CLARITY Ol
USER-FEE,
SHORTAGES OF
RESOURCES
COMMON. LONG
PROCEDURES,
OVERCROWDING,
LACK OF FOLLOW UF
ACCEPTABLE
QUALITY OF
SERVICES ;
COMMITTED STAFF.
EXISTING PVT
PRACTITIONERS MA'
BE TRAINED AND
INVOLVED WITH
INCENTIVE OF PER
UNIT OF SERVICE.
EXISTING PPM
APPROACH OF
RNTCP CAN BE
HELPFUL
INITIALLY, SOME
SEED MONEY MAY B
GIVEN TO START THI
28
PROJECT
COOPERATIVE
SOCIETIES MAY BE
ROPED- IN
UNDER
STAFFING OF
THE MEDICAL
OFFICERS/
ANMS
APPOINTING MEDICAL
OFFICERS & ANMS ON
CONTRACTING IN BASIS
UTTRANCHAL GOVT.
HAS MADE EFFORTS
IN APPOINTING
MEDICAL OFFICERS
& ANMS. THIS HAS
BEEN DONE IN VIEW
TO IMPROVE
HEALTH SERVICES
IN REMOTE AREAS
AND GIVEN THE
DIFFICULTY IN
RETAINING
SERVICES OF
PROVIDERS DUE TO
LACK OF
ACCOMMODATION
AND LOW SALARY.
NO EXTRA BURDEN ON
INFRASTRUCTURE AS
FUNDS CAN BE POOLED
FROM THE FUNDS UNSPENT
DUE TO VACANT POSITIONS
TO RETAIN THE
SERVICES GOVT.
HAS INCREASED
THE HONORARIUM
OF CONTRACTUAL
MEDICAL
OFFICERS FROM
11,000 PER MONTH
TO RS. 13000 PER
MONTH W.E.F. FEB
2004.IN ORDER TO
PROMOTE
INSTITUTIONAL
DELIVERIES. 24
HOURS DELIVERY
SERVICES ARE
BEING PROVIDED
IN 85 HEALTH
CENTERS AND
CERTAIN
INCENTIVES ARE
PROPOSED FOR
SERVICE
PROVIDERS WHO
CONDUCT
DELIVERIES
BETWEEN 8.00 PM
TO 7.00 AM.
LOCALLY
PRACTICING
DOCTORS AND
STAFF MAY BE
GIVEN PRIORITY
AS THEY MAY FIND
THE AMOUNT
ACCEPTABLE.
REGULAR REVIEW
OF SCHEME IS
NEEDED
NATIONAL HEALTH PROGRAMMES
FAMILY
WELFARE
PROGRAMME
CATARACT
CONTACTING
WITH THE
NGOS
1459 PRIVATE
HOSPITALS ARE
APPROVED FOR
PERFORMING
VASECTOMY.
TUBECTOMY, MTP
AND OTHER
CONTRACEPTIVES.
GOVT. PROVIDES BASIC
SERVICES WHERE NGO CAN
PROVIDE BEDS, SURGICAL
ITEMS TO PERFORM
STERILIZATION SERVICES
DRUGS CHARGES
AND OPERATING
SURGEONS FEES
ARE PAID BY THE
GOVT. PAYING
COMPENSATION
TO STERILIZATION
ACCEPTOR.
OPERATIONAL
COST IN GOVT
SET-UP MAY BE
CONSIDERED AS
SERVICE CHARGE
TO PVT
PROVIDERS.
ADVANCE
PAYMENT WILL
IMPROVE
PERFORMANCE
CONTRACTING
CERTAIN NCOS LIKE
NGOS CAN PERFORM
SOME 100 PRIVATE
29
BLINDNESS
CONTROL
PROGRAMME
WITH PRIVATE
SECTOR
(NCOS)
TB CONTROL
PROGRAM
PARTNERSHIP
WITH PRIVATE
PRACTITIONER TO GIVE
IECON THE DOTS
SCHEME AND FOR
IDENTIFICATION AND
TREATMENT OF THE
PATIENTS, GOVT. LABS
ARE OPEN FOR THE USE
BY THE PRIVATE
PRACTITIONER FOR TB
DIAGNOSIS
AIDS CONTROL
PROGRAMME
PARTNERSHIP
WITH NCOS TO SPREAD
AWARENESS ABOUT
THE HIV/AIDS , MAKING
FREE CONDOMS
AVAILABLE TO THE
PEOPLE BY NCOS
PARTNERSHIP WITH
PRIVATE DOCTORS /
NGOS. NGOS CAN
CONDUCTS PULSE
POLO CAMPS, PRIVATE
DOCTORS CAN GIVE
POLIO DROPS TO THE
UNDER FIVE CHILDREN
THOSE WHO VISITS
THEM AS PATIENTS OR
WITH PATIENTS
CONTRACTING WITH
THE PRIVATE HOSPITAL
PULSE POLIO
PROGRAMME
RCH PROJECT
VHS, CHRISTIAN
MISSION HOSPITAL,
ANDHRA MAHILA
SABHA, F.P.A.I. ETC.
ARE GIVEN ANNUAL
GRANTS BY
GOVERNMENT FOR
THEIR RECURRING
EXPENDITURE. THIS
IS APPLICABLE TO
CERTAIN
DISPENSARIES RUN
BY NCOS IN TRIBAL
AREAS ALSO.
CATARACT SURGERIES,
ARRANGE EYE CAMPS
WHERE GOVT PROVIDES
FINANCE.
MAHAVIR TRUST
HOSPITAL,
HYDERABAD,SEWA
AT AHMEDABAD
AND, MANAV
SARTHAK
KUSTHASHRAM,
JAIPUR ARE SOME
OF THE SUCCESS
STORIES
SPREADING AWARENESS
THROUGH PRIVATE
DOCTORS IS COST FREE.
OPENING THE LABS FOR
USE BY THE PRIVATE
DOCTORS CAN DIAGNOSE
MORE TB PATIENTS AND
TREATMENT OF THE SAME
UNDER RCH
PROJECT
HOSPITALS ARE
APPROVED FOR
UNDERTAKING
MAJOR
SURGERIES
UNDER THE ABOVE
SCHEME.
ONLY ACCREDITED
NGOS HAVING
SKILLED
MANPOWER
SHOULD BE
CONSIDERED.
HOSPITAL
CREATES A
REFERRAL CARD,
INITIAL DIAGNOSIS
.COUNSELING ,
AND TREATMENT
PROTOCOL AND
REFERS THE
PATIENT TO
DESIGNATED DOTS
CENTER FOR
DRUGS. GOVT
PROVIDES FREE
DRUGSAND
MEDICINES TO THE
DOTS CENTERS
ALSO TRAIN
MEDICAL STAFF.
PROVIDES LAB
SUPPLIES,
PRIVATE MEDICAL
PRACTITIONERS
REFER PATIENTS
MODEL OF RNTCP
HAS STRONG
POTENTIAL FOR
ADOPTION IN ALL
NHPS
WITH NO EXTRA COST
GOVT CAN SPREAD HIV/
AIDS AWARENESS AND
PROVIDE CONDOMS TO THE
PEOPLE
MONITORING IS
MUST
WITH INVOLVEMENT OF
PRIVATE PEOPLE
PROGRAMME CAN BE
IMPLEMENTED MORE
EFFECTIVELY WITHOUT
ANY BURDEN ON EXISTING
INFRASTRUCTURE
VACCINE
PREVENTABLE
DISEASES ARE
ALSO ISSUED
FREE OF CHARGE
TO PRIVATE
NURSING HOMES
FOR THEIR USE
EFFECTIVE AND ECONOMIC
RCH & FAMILY WELFARE
FUNDS FOR THE
SCHEME WILL BE
30
7
UNDERTAKE LSCS
SURGERIES WHERE
GOVT SERVICES ARE
NOT; AVAILABLE. FEES
AREMET^BYGOVT.
HOSPITAL,
OBSTETRICIANS,
< ANESTHETIST CAN BE
cy-c -”■ LJiotrr,
HIRED^OR iLSCS
SURGERIES IN GOVT
HOSPITAL WHERE .THEY
ARE NOT AVAILABLE.
MTP SERVICES ARE
ALSO PROVIDED IN THE
PRIVATE HOSPITALS
AGAINST THE
VOUCHERS WHICH
REIMBURSED AFTER
EVERY MONTH FROM
THE STATE GOVT.
INNOVATIVE MODEL
LIKE VIKALP ARE
GOING ON.
DELIVERY HUTS MAY
BE HANDED OVER
TO NGOS ALREADY
INVOLVED IN RCH
SERVICES CAN BE
PROVIDED TO THE PEOPLE
PROVIDED FROM
THE DEPARTMENT
OF HEALTH,
HARYANA TO THE
MOTHER NGO FOR
FURTHER
PAYMENT. THE
PAYMENT WILL BE
MADE OUT OF THE
FUNDS AVAILABLE
VOUCHER
SCHEMES UNDER
THE RCH H
PROGRAMME. AN
AMOUNT OF RS 1.5
CRORES IS
AVAILABLE FOR
IMPLEMENTING. •
VOUCHER
SCHEMES IN THE
VEANORMS
™S
FOR HE
PAYMENTS WILL
BE FINALIZED
AFTER..:
NEGOTIATION
BETWEEN MNGOS
AND PRIVATE
PROVIDERS.
ADVANCE
PAYMENT IN FIRST
QUARTER MAY BE
EXPERIMENTED
31
Annexure-2
MODELS OF PUBLIC PRIVATE PARTNERSHIPS
Various models can be utilized for putting these partnerships into action; some of the
possible mechanisms for implementation of PPP are given below:
1. Franchising
Franchise is a type of business model whereby a manufacturer or marketer of a product or
service (the franchiser) grants exclusive rights to local independent entrepreneurs (franchisees)
to conduct business in a prescribed manner in a certain place over a specified period. Typically
the franchiser has developed specialized skills, knowledge, and strategies and thus able to share
its blueprint for a successful product line with franchisees. The franchisees contribute resources
of their own to set up a clinic and pay membership to franchiser.
Partial Franchising: Most of the social franchising models followed in India are partial
franchising models. Franchiser identifies private hospitals and enters into an agreement with
franchisee to provide certain services in lieu of payment of fee or commissions from sale of
services and goods. These contracts largely confine to a basket of RCH services. However
franchisee provides many other services that are not part of the contract. There is no control over
quality of services provided by franchisee outside the contract.
Usually one-year subscription fee is given by franchisee to franchiser. In this arrangement,
increased performance of franchisee does not lead to increased revenues to franchiser. There is
no incentive to franchiser to improve performance through promotional activities. One way to
overcome this problem is to have a revenue sharing arrangement between franchiser and
franchisee. However many of the hospitals are not transparent about their financial transactions
or do they maintain complete record of services provided. One of the innovative aspects of these
social franchising efforts is to link rural medical practitioners and/or community based
organizations such as SHG to franchisee that has helped to increase the client load for RCH
services. The partial franchising efforts in India do not represent public-private partnerships but
offer a model and experiences that are highly relevant. Government can have its own model of
social franchising with franchiser-franchisee-RMP-CBO linkages. Concentration of private
hospitals/ nursing homes in urban areas has to be taken into consideration. In many rural and
inaccessible areas where the need for improved access to services is the highest, there are not
private hospitals/nursing homes.
Full Franchising: Franchisee provides services defined by the franchiser and expansion of
range of services depends on mutual agreement. For existing nursing homes and hospitals, this
can mean a considerable revenue loss and this has to be filled in by subsidies till the client load
improves and the hospitals start making operating profits. Time required for transition of loss
making unit to profit making unit depends on a variety of factors such as location of hospitals,
demand for services, perceived quality of services and competition. Not many hospitals may opt
for this given the uncertainties in financial returns, unless guarantees are given to sustain the
model for a long period of time.
2. Branded Clinics:
A few organizations have started a chain of branded clinics that offer a wide range of reproductive
and child health services. There is scope to expand the range of services provided by these
clinics and add social mobilization efforts to their functions. These branded clinics can be opened
in areas where there is a need with minimum effort. Branded clinics are more sustainable
because of their ability to generate more income than social franchising units.
32
3. Contracting Out
Contracting out refers to a situation in which private providers receive a budget to provide certain
services and manage a government health unit. The two parties usually agree on some or all of
the following: the quantity and the quality and the duration of the contract.
Common criteria for identifying those government health clinics that need to be contracted out are
the first step in this direction. Large number of vacancies for a long period, high absenteeism, and
consistent low performance on all RCH indicators could be the critical criteria.
Some states are more prepared for contracting out services compared to others. Fear of losing
jobs and perceived shrinking role of government in health sector are the main reasons for
resistance. Advocacy efforts are required in those states where resistance levels are high for
contracting out services.
There are several levels at which the contracting out can be done depending on the degrees of
freedom given to the contractor. Higher the freedom, higher should be the performance levels of
key RCH indicators.
Option 1:
Option 2:
Option 3:
Option 4:
Government hands over the physical infrastructure, equipment, budget and
personnel of a health unit to the selected agency.
Government hands over the physical infrastructure, equipment, budget but gives
freedom to the selected agency to recruit personnel as per their terms and
conditions but following the government norms such as one ANM per
5,000/3,000 population.
Government hands over the physical infrastructure, equipment, and budget but
gives freedom the select agency to have their own service delivery models
without following the fixed prescribed pattern.
Government hands over the physical infrastructure, equipment, budget and gives
freedom to the select agency to have their own personnel, service delivery
models, freedom to expand types of services provided and freedom to introduce
user fee and recover some proportion of costs.
4. Contracting In
Contracting in is done for a variety of services particularly in major hospitals. These include:
maintenance of buildings, utilities, housekeeping, meals, medicine stores, diagnostic facilities,
transport, security, communications etc. Hospitals are given freedom to choose the services to be
given to contractors. In many cases they lack comprehensive plans and sound financial analysis.
Nevertheless, contracting in many hospitals has resulted in conservation of resources, improved
efficiency and better quality of services. Contracting in services leads to surplus human resources
and they need to be transferred to other health units to fill in vacant positions, if any. Resentment
of employees and interference of trade unions are some of the major obstacles to this process.
Contracting in does not work in some places for particular types of services. For instance some
state governments could not attract private sector participation for diagnostic services in remote
area hospitals with low client load. One option is to subsidize the equipment purchased by private
agencies and the other is to make services located in government hospitals open to all. Even a
person with prescription from private clinic should be allowed to use privately run diagnostic
facilities in government hospitals. This increases the volume of transactions and makes the unit
financially viable.
Recruiting doctors, technicians and other staff on contractual basis for a stipulated period of time
is widely practiced in several states. In some cases the contracted staff performs all duties of
regular staff and in other instances, their services are contracted for a few days in a month and to
provide services in a particular clinic. In many states, a large proportion of vacant positions were
filled in following this process.
33
5. Social Marketing
One of the earliest efforts at building public-private partnerships is in the area of social marketing
of contraceptives. For more than a decade, HLL, ITC, Indian Oil and other large FMCG
companies helped the government with social marketing of contraceptives by piggy backing
Nirodh to their products. Later private social marketing companies have emerged as a force to
reckon with and gained considerable experience in marketing contraceptive products both social
and commercial. The increasing trend now is to enlarge the basket of products by including ORS,
I FA tablets, and other health products to make the marketing efforts more self-sustaining.
Government provides the subsidized contraceptives, and finances brand and point of purchase
promotion schemes of selected marketing agencies.
6. Build, Operate and Transfer
Build, operate and transfer (BOT) models are highly successful in infrastructure development
sector in India. BOT requires part financing of projects by the government, financial guarantees
when needed, subsidized land at prime locations and assurance of reasonable returns on
investment. These models could be useful to establish large hospitals and ensure quality services
at reasonable rates to poor people. However these hospitals should be able to withstand market
competition to survive and sustain themselves.
7. Joint Venture Companies
Joint venture companies are companies launched with equity participation of government and
private sector. Proportion of equity of each partner may vary from one venture to another. Joint
venture companies, in most cases in commercial sector, have not succeeded in India due to lack
of understanding and trust between partners, inordinate delays in decision-making and
dominance of government even with low equity. There is even less chance of their succeeding in
health sector.
8. Voucher System
A voucher is a document that can be exchanged for defined goods or services as a token of
payment (tied-cash"). This consists of designing, developing and valuing health packages for
various common ailments / conditions (like ANC package / STI package / Teen pregnancy
package / family planning package etc) which can be bought by the people at specific intervals of
time. These vouchers can then be redeemed for receiving a set of services (like 1-2
consultations, lab tests, procedures, counselling and drugs for the condition) from certified /
accredited hospitals or clinics and are to be used within 2-3 months of buying the voucher. This
means that the package can be bought, used as and when required and ensures privacy for the
client.
Regular monitoring is required for ensuring quality standards, training of providers and networking
with the people to ensure that the proper use of vouchers. The vouchers are redeemed to the
clinics for the number utilised depending on the price for each package of service provided.
Clinics that fail the quality standards of service and do not do well on patient satisfaction can be
removed from the certified services.
9 Donations from individuals
Within a large country like India and with a creditable high income and middle income groups
there are many examples of private donors willing to partner with the public sector. Rich
philanthropists, individual donations may be the crucial requirement in areas to make the PPP
initiative effective in delivering health care. Though in some states mechanisms and provisions
are present for utilizing these private donations for improving local health situation, many other
states lack these systems. Efforts have to be made to create simple and transparent institutional
mechanisms to encourage donations to contribute to the growth and improvement in reproductive
and child health services in their area.
34
10. Partnerships with Social Clubs and Groups (e.g. Rotary Club)
Clubs like Rotary and Lion’s played a significant role in immunization campaigns, Pulse Polio
campaign and other health care services. Since these clubs have a nation wide network, their
involvement ensures better coverage. They also bring in their expertise and resources to the
health care services.
11. Involvement of Corporate sector:
The corporate sector has a rich history of being supportive of the health and family welfare
interventions for people that work in and live around its premises. Under Corporate Social
Responsibility, the corporate sector through the Confederation of Indian Industries (ClI) and the
Federation of Indian Chamber of Commerce and Industries (FICCI) and several other sector wise
business and industry associations have played a significant role in advocacy efforts, funding
non-government organizations for innovative interventions, introducing new schemes to
encourage service utilization and expending their own resources for promotion of reproductive
and child health services particularly family planning services..
12. Partnership with Professional Associations
There are several professional associations such as Indian Medical Association, Gynaecologists
federation, nurses associations etc. These association from time to tome extended help in
launching new programmes such as Vande Mataram Scheme, Gaon Chalo project and
immunization programme particularly pulse polio. They have technical skills and expertise to
provide advice on various other matters such as setting standard protocols, quality assurance
systems and accreditation. However the managerial capacities of these professional associations
have to be strengthened.
Moreover, with widespread chapters/ branches all over the country and huge membership they
can play a very important on ethical issues.
13. Capacity building of private providers, pharmacists and informal providers (RMPs)
Several initiatives taken by the government in the past to improve the technical and counselling
skills of private medical practitioners particularly rural medical practitioners by providing them
training improved quality of services offered by them. Since they have a huge presence in rural
areas and urban slums and a significant proportion of population depend on them for services,
there is a need to involve them in a significant way to create demand for services and in making
referral system effective. Similarly government medical officers and administrator benefited by
participating in training programmes conducted by private institutions. Consultancy services
offered by private institutions in the areas of communications, systems development etc is
another example of public-private partnership. Another area of partnership is contracting out
management of training institutions such as ANM Training Centres, Regional Training Centres to
NGOs and private agencies.
14. Special “Category Campaigns” with the private sector to improve health
The WHO-ORS campaign and the Goli- ke- Hamjoli campaigns are examples of the use of the
commercial sector to advance national health goals. The category campaigns expand use of a
health/family-planning product, increases the volume and the users for the product. In India, the
Goli ke Hamjoli and WHO-ORS campaigns succeeded in increasing product awareness,
availability, sales, and use. At the same time, this entails using a generic promotional strategy,
increased private-sector investment and the value of the market, policy change; coordination with
partner pharmaceutical firms; affiliation with professional associations; expansion of market
channels; and consumer outreach. Initially, the program should use mass media vehicles to
improve product awareness and contemplation. But, as the program develops, its emphasis
should shift to encouraging product trial, and use interpersonal approaches to reach out to
potential consumers.
35
These special campaigns in partnership with the private sector can focus on demand generation
for refurbished and revitalised public sector, generic promotion of health products (life saving
ORS, Menstrual Hygiene with Sanitary Napkins etc).
15. Autonomous Institutions
Giving autonomy to public institutions within the system can lead to improvement in quality,
accountability and efficiency. It also ensures greater involvement and ownership at the level of
the institution, ensuring greater morale and encouragement to the work-force. Many such projects
have been implemented and have shown to yield excellent results, as the need for the change in
management systems is self-driven. This is also sustainable and easy to replicate.
16. Partnering with CBOs / NGOs
For designing and implementing innovative approaches to RCH services, partnerships with
community based organizations and non-government organizations are a significant step.
Government for long encouraged participation these grass roots organizations in demand
creation and delivery of services. These organizations often worked in remote rural areas where
access to RCH services is difficult. Recent NGO Policy of the MOHFW envisages a scheme
where each district would have a mother NGO and linked to several field NGOs within the district
with greater degree of autonomy and decentralization. Community mobilization efforts yield
effective results and community ownership of the programme is sustainable.
17. Mobile Health Vans
In geographical areas with difficult terrain with no transport facilities and poor road connectivity
usually the outreach and institutional services of PHCs are not to the expected standards. This
has resulted in gross under utilization of services. To overcome this problem, in some states
private sector agencies have taken a lead in launching mobile vans. These vans go to clearly
identified central points on fixed days and provide comprehensive health services including RCH
services to a cluster of villages. While private sector resources were put to use to purchase vans,
the government contributed to these services by deputing medical officers and medicines. This
approach has significantly helped to improve access to quality services.
18. Insurance and Public-Private Partnerships
In one of the recently planned schemes, the government insures and pays health insurance
premium for families below poverty line. These families in turn are insured against expenses on
health and hospitalization, up to a certain amount. On similar principle, it is possible to develop
sustainable health insurance schemes that are community based. In such schemes, the
community members pay a minimum insurance premium per month and get insured against
certain level of health expenditure. This protects them from sudden and unexpected expenditure
on health. Such community based schemes also ensure that the local needs and expectations of
the people are met, by preferentially reimbursing local trained healthcare providers.
CLASSIFYING PPPs
Since public-private partnerships vary significantly, it is necessary to categorize them in order to
understand their nature and thrust areas of partnerships. Some of the partnerships are for short
duration or one time activity and others are for long term. These partnerships also work in specific
thrust areas. Some of the partnerships may cover all thrust areas and others one or more.
Nature of PPP
Examples
One time /Short term
Partnership
Donation of land, money, equipment etc
Participation in campaigns
Continuous / Long term
partnership
Social franchising of service
Contracting In and Out
Social marketing
Capacity building
36
Thrust areas of partnership
Examples
Service oriented
Social Marketing
Social Franchising
Contracting healthcare providers
Mobile vans____________________________
Contracting out IEC activities to NGOs
Category Campaigns with Private Partners
Information
oriented/Advocacy oriented
Infrastructure oriented
Capacity building oriented
Construction of buildings
Repairs to buildings
Equipment, Vehicles_____________________
Training for skill development and counselling
Systems development
Managerial capacity
CRITERIA FOR INITIATING PPPs
Types of public-private partnerships relevant for a particular state depend on prevailing
conditions, needs and functional requirements. Some criteria by which the public-private
partnerships should be selected are given below, as follows:
Form of Partnership
1. Franchising
Criteria for initiation
. The effort to revitalize the complete govt, infrastructure is time
consuming and a slow process
• Resources required to expand public health infrastructure is
enormous.
. Need for services is enormous and the government health
institutions are not in a position to cater to needs
• Availability of vast network of private hospitals in places needed
• When objective is to improve access to services on immediate basis.
. Improve quality standards of private sector and provide high quality
care at affordable prices.
2. Branded Clinics
3. Contracting Out
37
Contracting In
•
•
•
•
5. Social Marketing
•
•
•
•
6. Build Operate
Transfer (BOT)/ Joint
Ventures
•
•
Voucher System
•
•
•
•
•
•
•
8. Donations from
individuals
•
•
•
•
9 Partnerships with
Social Clubs and
Groups (eg. Rotary
Club)
•
10. Involvement of
Corporate sector
•
•
•
•
•
•
•
Improve efficiency levels of services provided
Make management of services more effective
Conserve scarce resources by cutting costs
Try out innovative approaches to improve efficiency and
effectiveness________ .
________
Combine service delivery with demand creation
Availability of products in a vast network of easily accessible retail
outlets
Encourage brand choices and competition to improve penetration
levels
Perceived value attached to priced products than products
distributed free of cost___________________________________
An enormous number of service delivery points whether hospitals,
labs or diagnostic centres have to be constructed within a short span
of time.
When the cost of building and maintaining a unit is prohibitive for the
govt, to bear alone
When returns on investment are guaranteed.
Government treats health as infrastructure industry.
_____ __
Improve access to services and provide choice
Costs act as a major barrier to services
Existing service delivery points do not have provision to all types of
services
Inadequate knowledge about the value of service (eg importance of
antenatal care)
Generate demand for services particularly among poor and
disadvantaged sections
_________________________
Presence of affluent families, philanthropic organizations
Identified needs to improve quality of services
Clear procedures and guidelines to accept donations
Transparent and accountable systems that enhance image of
institutions__________________________________________ _
Partnerships to popularise revitalized service points, communication
campaigns and logistics management
Organization of camps on a large scale
Need for additional resources and also management and technical
expertise
Need to step up advocacy efforts___________________________
Resources to outreach services through NGOs in remote areas
Effective services to employees in organized sector
Policy advocacy efforts
Adoption of villages or CHCs/PHCs by corporate health sector to
38
11. Partnership with
Professional
Associations
•
•
•
•
•
•
12. Capacity Building
of Private providers,
pharmacists and
Informal providers
(RMPs
•
•
•
•
•
•
“Campaigns with the
Private Sector to
improve health
14.Autonomous
Institutions
•
•
•
Presence of active professional associations with clear guidelines
Internal committees to promote ethical practices
Management expertise to implement projects
Need to prepare standard protocols, quality assurance system by
building consensus
Improvement of technical skills of professionals in both private and
public sectors
Improve professional response to programme needs
High dependence of people on private sector for services
Technical knowledge and skill levels are not to a desirable standard
Improve quality standards of providers and increase access to
quality services
Put in place an effective referral system
Involve services providers in social marketing efforts
When the need to promote a service or health care product is
established
Multiple partner involvement is required to promote a product
Advocacy efforts to make product acceptable at all levels
•
•
•
•
Need to upgrade quality of services and initiate use of state-of-theart technology in health care delivery
Provide enough flexibility to health units
Improve efficiency and effective levels of management
Reduce costs and facilitate quicker decision-making
!
Allow institutions to generate alternate sources of funding
15 Partnering with
NGOs/CBOs
•
•
•
•
Encourage community involvement
Improve community ownership of programme
Test innovative and cost-effective approaches to service delivery
Cover inaccessible and remote areas
16. Mobile Clinics
•
•
•
Provide access to services people living in inaccessible terrain
Make services available at central location to reduce travel time and
costs of clients
Improve utilization of services in remote areas
•
•
•
•
«
Focus on poor and disadvantaged
Provide services at affordable costs
Long term solution to health problems
Improved choice of health units
Reduce indebtedness among poor due to health costs
17. Insurance
Schemes
39
Annexure 3
References:
1.
Prof N K. Sethi etall: Public Private Partnership in the Health Sector in India:
Initiatives in selected States
2.
Planning Commission, Gol: Report of the PPP Subgroup on Social Sector
November2004:
3.
Ravi Duggal, VHAI: The Private Health Sector in India: Nature Trends and Critique
4.
NIHFW: National Planning Workshop on Public Partnerships in the Health Sector in
India,2005
5. A Venkat Raman and James Warner Bjorkman: Public Private Partnership in Health
Care Delivery in India
6.
MoHFW: The Report of the Task Force on Medical Education, 2006
7.
National Sample Survey Organisation (NSSO): Report on the 60th Round
8.
Source for Graphs: Pearson M, Impact and Expenditure Review, Part II Policy
issues. Draft DFID, 2002
40
Annexure IV
CHIRANJEEVI-THE CONCEPT
For reduction in maternal and child deaths /
access and equity
In five backward districts
For EmOC and Em transport services
With weak Public Health Facilities in Obstetric
care
In Partnership with FOGSI
For making available private specialists to BPL
pregnant woman
Unit cost Rs 1795/- based on package of
services includes:
CHIRANJEEVI-THE CONCEPT-II
• Rs200/- for transport to pregnant mother
• Rs 50/- for midwife or attendant
• Pvt gynaecologist pays above and avails
reimbursement
• ANC Registration in a Govt facility a must
• Advance of Rs 15000/- to the pvt
gynaecologist
• CDMHO empanels and monitors
41
DISTRICT-WISE PERFORMANCE OF
DELIVERIES UNDER CHIRANJIVI YOJANA,
GUJARAT
Progress Dec 05- March06
District
Total
number of
Private
specialists
Number of
Private
specialists
enrolled
Deliveries
under
Chiranjivi
Yojana till
Average
performance
per Doctors
Panchmahal
29
27
2313
86
Sabarkhanta
73
46
1897
41
Banaskhanta
50
52
1436
28
Kutch
47
20
726
36
Dahod
16
18
1421
79
Total
215
73.6%
7793
48
CHIRANJEEVI-OUTCOMES
• 163 Molls signed. 76% enrollment
• 87% Normal and 5% Caesarian delivery
• Avg Delivery per specialist is 48
• 31% (2415)of 7793 BPL pregnant mothers have
delivered
• No maternal death reported. As per MMR 30
mothers would have died
• 9 infant deaths reported. As per IMR 350-450
infants would have died
• Access of BPL pregnant mothers to institutional
delivery
42
ARUNACHAL PRADESH
EXPERIMENT : THE CONCEPT
• Pilot Project: 90% Govt
10% NGO
• State hand over infrastructure of PHC/SC
to Agency
• State to provide cost towards personnel,
drugs and consumables
THE CONCEPTS)
• Agency to engage its own staff and ensure
availability 24X7
• Staffing Pattern
MO - 2
<=> Pharmacist - 1
Staff Nurse - 2
ANM - 2 (PHC)/6 (SC)
■=>
LHV-1
■=>
lab tech -1
■=>
Driver -1
HA(Jr.)-1
<=> Group D - 4
43
«
THE CONCEPT (3)
Agency to provide all services expected of a PHC
PHC Management Committee-RKS
State Steering Committee
National level NGOs
Exit policy for Agency and Govt
Audit and Accounting
Output based performance indicators
Outreach Activity
Implementation of National Programmes
External Evaluation/Concurrent evaluation
PARTNERS IN AP
• Karuna Trust
: 9 Districts
• VHAI
:5 Districts
• JAC(Prayas)
: 1 District
• FGA, Itanagar
: 1 District
44
Position: 4700 (1 views)