Keynote Address: Stewardship and Governance in Health Systems with special reference to the National Rural Health Mission.-Amarjeet Sinha

NRHM – REINVENTING SYSTEMS

Stewardship and Governance in Health

Amarjeet Sinha

Understanding India

• Over a billion people in over a million places.• Persistence of poverty and under nutrition.• Low public exp./high out of pocket on health.• Regional disparities – Kerala/TN & Orissa/Bihar.• Large unregulated private sector – need to

engage with not for profit and for profit.• Medicalized versus health – water, sanitation.• Medical – para medical divide.• Human resource challenges - urban - rural.

The Health Scenario• Multiple burden of disease – communicable, non-

communicable; unattended morbidities.• High Child and maternal deaths. • 50% under- nourished and anemic women and

children – very little improvement.• Water and sanitation challenges remain.• Food security is an issue.• Malaria, dengue, chikanguniya – on the rise.• Public health regulation – very weak. • High TFR in UP, Bihar, MP, Rajasthan, Jharkhand.

Public Policy -Getting basics right • Theory without practice is as dangerous as practice

without theory• Begin from the problem; do not impose a solution

without looking at the problem.• I don’t care what colour is the cat, as long as it

catches mice – pragmatic, evidence based, not ideological!!!

• The map is not the territory!!!• Samakhya – Dialogue of equals !!!• If you do not do what you have to do, you will

never be able to do what you want to do !!!!

NRHM – What is different………• A true partnership with States.• Space for innovations.• Distrust to trust.• Community institutions as focus.• A worker, an institution and an event in every

village – ASHA, VH&SC, VHND.• Public health focus – addressing local specific

mortality and morbidity.• Building capacities for local action.• Recognizing the need for management skills.

NRHM – ALMA ATA +

PHCPHC

Alma AtaAlma AtaApproachApproach

Health Education

Nutrition&

Food Security

Safe Water&

Sanitation

Maternal andChild Health

Family Planning

Immunizationagainst

InfectiousDisease

AppropriateTreatment of

Common diseasesAnd injuries

Prevention & controlof locally endemic

diseases

Provision ofessential drugs

HUMAN RESOURCES - Community Workers. - Nurses and Doctors. - Public Health Cadre. - Multi skilling Specilaists.

PRIMARY HEALTH CARE - Malaria, TB, NHPs - Doctor, drugs, diagnostics. - Nursing promotion. - women and child thrust. - Adolescent Health.

PREVENTIVE HEALTH - Water and sanitation - Public Information - Immunization - Vector control

WATER AND SANITATION AND NOT ANTIBIOTICS

Improving public healthHEALTH PROMOTION - Sports and Yoga. - Healthy food. - Healthy habits. - Age at marriage.

SECONDARY AND TERTIARY - Hospitalized care in government and private. - Cashless services. - Rational and ethical practice.

NUTRITION - Key to good health - Link of childhood under- nutrition and adult diseases - Cultural aspects – oil use.

Rejuvenate the Health delivery System

Universal Health Care Access

AffordabilityEquity Quality

Reduce IMR, MMR,TFRImprove Disease control

National Rural Health Mission launched in April, 2005

NRHM – Main Approaches

9

COMMUNITIZE

1. Hospital Management Committee/ PRIs at all levels2. Untied grants to community/

PRI Bodies3. Funds, functions &

functionaries to local community organizations

4. Decentralized planning,5. Intersectoral Convergence

IMPROVEDMANAGEMENT

THROUGH CAPACITY

1. Block & District HealthOffice with management skills2. NGOs in capacity building

3. NHSRC / SHSRC / DRG / BRG4. Continuous skill development

support

FLEXIBLE FINANCING

1. Untied grants to institutions 2. NGOs for public

Health goals3. NGOs as implementers

4. Risk Pooling – moneyfollows patient

5. More resources formore reforms INNOVATION IN

HUMAN RESOURCEMANAGEMENT

1. More Nurses – localResident criteria

2. 24 X 7 emergencies byNurses at PHC. AYUSH

3. 24 x 7 medical emergencyat CHC

4. Multi skilling

MONITOR,PROGRESS AGAINST

STANDARDS

1. Setting IPHS Standards2. Facility Surveys

3. Independent MonitoringCommittees at

Block, District & Statelevels

BLOCKLEVEL

HOSPITAL

30-40 Villages

Strengthen Ambulance/transport ServicesIncrease availability of NursesProvide TelephonesEncourage fixed day clinics

AmbulanceTelephone

Obstetric/Surgical MedicalEmergencies 24 X 7

Round the Clock Services;

BLOCK LEVEL HEALTH OFFICE –--------------- Accountant

CLUSTER OF GPs – PHC LEVEL

3 Staff Nurses; 1 LHV for 4-5 SHCs;Ambulance/hired vehicle; Fixed Day MCH/Immunization

Clinics; Telephone; MO i/c; Ayush Doctor;Emergencies that can be handled by Nurses – 24 X 7;

Round the Clock Services; Drugs; TB / Malaria etc. tests

GRAM PANCHAYAT – SUB HEALTH CENTRE LEVEL

Skill up-gradation of educated RMPs / 2 ANMs, 1 male MPW FOR 5-6 Villages;Telephone Link; MCH/Immunization Days; Drugs; MCH Clinic

VILLAGE LEVEL – ASHA, AWW, VH & SC

1 ASHA, AWWs in every village; Village Health DayDrug Kit, Referral chains

100,000 Population

100 Villages

5-6 Villages

Accredit private providers for public health goals

Health Manager

Store Keeper

NRHM – Illustrative Structure

What is the Change ?

• Health – a priority in States as never before.• Public health thrust recognized.• NRHM – A platform for innovations.• NRHM – A Framework for decentralization.• Human Resource as priority.• Community Worker – connecting households • A statement that public systems can deliver.• Managers of the system – professional skills.

Key New Developments• Multi-skilling of Doctors – LSAS, EmOC.• Emergency Transport – Diversity of models.• Mobile Medical Units.• Local Criteria in selection.• Developing locals as health workers.• Incentives for remote areas.• Primacy to nursing – over 75,000 added.• Over 800,000 ASHAs – connecting households• Over 15,000 MBBS Doctors, Specialists, AYUSH.• Untied Grants to institutions – Guarantee services.• Community Monitoring – AGCA; ASHA Mentoring; MSG.• Enhanced drug Budgets.• Demand generation and supply side strengthening – partnerships.

KEY STATE LEVEL HEALTH SYSTEM INSTITUTIONS & FUNCTIONS

Directorate of Tertiary Care/Med. Edn.

• Medical/Nursing/ Paramedical Education

•Training and Skill Development

The Key Health System Institutions

(Admn Div., Nursing Div. and Financing Div. along with each directorate)

Directorate of Hospital Services• Hospital Services (District/Sub-dt. Hospitals)• Emergency Services

Directorate of Public HealthPrimary Health Care (up to Block Level)

Disease control Programmes

RCH Programmes:

SIHFW

In service skills Development

Pre-service training programmes

State PMU:

• HMIS & Evaluation:• Extra-Budgetary Fund Flows• HR : contractual staff.• Addl. Capacity for Programmes

Medical ServicesCorporation

• Procurement,• Logistics• Infrastructure Development

Health Regulation

Pvt. Sector; Food & DrugsPPPs, Insurance

AYUSH

SHSRC

• State/Dt. Planning :- Pgm. Design, Financing, HR, Governance, HMIS• Community Processes

Emerging Stewardship and Governance Challenges

• Building Capacity for Public Health.• Managing higher financial resources.• Capacity for decentralization.• Evidence based approach.• Community Monitoring – Accountability.• A reliable, timely, facility specific, HMIS.• Institution – specific autonomy.• Transparent human resource management.

Managing for performance

•Appropriate skills•Training and learning•Leadership and entrepreneurship

•Satisfactory remuneration•Work environment•Systems support

•Numeric adequacy•Skill mix•Social outreach

Human resource actions

Competence:Training and

learning

Coverage:Social and physical

Workforce objectives

QualityAnd

responsiveness

Equitable access

Health outcomes

Health system performance

Motivation:Systems and

support

Efficiency and effectiveness

Health of the population

MANAGEMENT OF HEALTH SYSTEM

TASKS LEVEL TEAM

Supervision of servicesTraining of community Survey and mobilizationDistribution of drugsMonitoring/Reporting

Block Level Health Team

Block Medical OfficerBlock Resource Group

AccountantData Entry Assistant

Store Keeper

Planning and MISCapacity buildingMapping NGOs

Financial ManagementProcurement/Stores

Technical/Community

Planning and MISCapacity building

Financial ManagementProcurement/Stores

Technical/Community

District Level Health Team

DM – DMHOMgt. Expt. As ADHMO

Finance/Data/Proc.Tech./NGO/Community

State Level Health Team

Mission DirectorCoordinators – Technical,

Financial, MIS, M&E, Gender, NGO, Procurement,

BUILDING CAPACITY THROUGH RESOURCE GROUPS

TASKS LEVEL TEAM

Training of PRIs/CBOsSurveys/MISTraining ASHA/ANMDistribution/FM

BLOCK LEVEL

Block Health OfficeBlock Resource TeamRPs

Surveys/MIS/NGOProcurement/DataTraining/M&EFinancial Mgt.

Studies/SupervisionProcurement/MISTraining/PlanningFM/ M&E/NGOs

DISTRICT LEVEL

District Resource Group; PMU; Specially recruited skills ; DHM

STATE LEVEL

State level MissionSIHFW/Instns./NGOsResource Centre

Planning/supervisionMIS/M&E/Proc./FMNGOs/CommunityTechnical Skills

NATIONAL LEVEL

NHSRC/NIHFWMoHFWInstitutions

COMMUNITIZATION OF HEALTH CARETASKS LEVEL TEAM

Community actionSurvey/SupportPlanning/implementn

Village Health & Sanitation Committee

ASHA/AWW/PRISHG/CBONGOs

Planning/SurveyCommunity actionImplementation

Planning/ SupportSupervisionCommunity action

Sub Health Centre level, Gram Panchayat

Samiti

ANM/MPWPRI/NGOWomen’s groups

PHC level cluster level Committee

PHC MO/Para MedicsNGO/PRIWomen’s Groups

Planning/Implementation/

accountabilityPublic HearingsHealth Camps

CHC/Block PHC/ BMO level Panchayat

Samiti/ RKSBHO; RKS of CHC; Panchayat SamitiNGO/CBOs/ SHGs

Planning/ M&E/SupervisionAccountability

District level Health Mission under the Zila

Parishad

Zila Parishad; DM/CEO/DMHOPMU/NGOs

The impact of NRHM

• MMR significantly down – 450 to 230 as per UN Reports; 301 to 215-220 ( approx.) – SRS.

• IMR decline – 60 in 2004; 53 in 2008; 50 now?• TFR steadily declining – 2.9 in 05 to 2.6 in 2008.• Institutional deliveries – 41% to 73%• TB, Malaria, NPCB, Surveillance better.• Substantial addition of human resources.• Infrastructure – more and better managed.• Doctors, drugs and diagnostics – OPD, IPD.

NRHM – Institutional strengthening

• VHSc, PRIs, RKSs, DHMs, SHMs, MSG.• Joint Bank Accounts for VHSC and Sub Centres.• Registered Rogi Kalyan Samitis at PHC and above – legal

entity – opportunity for autonomy.• Flexibility and adequacy of funding with accountability

framework to ensure public action.• Decentralized planning and implementation.• States, districts, blocks, villages deciding priority for public

health action. • System for procurement and logistics – TNMSC.• Improving Human Resource Management. • HMIS – web enabled monitoring system.

NRHM – System strengthening• Financial Management – FMR, Audit, Managers.• Programme Management – SPMU, DPMU, BPMU.• Data Management – HMIS, Facility performance.• Development of Standards – IPHS, NABH, ISO.• Capacity development for public health – public

health management master’s (PHFI) and diploma (PHRN – IGNOU).

• Family Medicine programme – CMC Vellore• Professional Development Courses – NIHFW, SIHFWs• Accountability system – CRMs, Concurrent

Evaluation, Community Monitoring, Performance Audit of CAG.

NRHM – Fostering Innovations• Decentralizing thought and action.• Respecting local thought and action.• Providing platform for sharing and learning.• Intensive engagement in capacity development at all

levels.• Building systems that foster innovations.• Analytical feedback to States.• Crafting convergent and credible platforms at all

levels of care.• PUTTING PEOPLE’S HEALTH IN PEOPLE’S HANDS –

TAKING CHARGE!!!!

Examples of Innovations • Making PHCs 24X7 in Tamil Nadu – 3 Nurse model.• Assam’s initiative – Boat Clinics, Evening OPDs, ASHA.• Rajasthan’s initiative – RRHS; IEC; CMJRK;MMUs; SNCUs.• MP’s initiative – Janani Express, HSC Delivery, SNCUs.• Haryana’s initiative – Free drugs, 102; surgery package.• Gujarat’s initiative – Chiranjeevi, 108, NABH; Managers. • Kerala’s initiative – KMSC, Ban private practice; Quality.• Bihar – Block pooling; PPPs – Diagnostics.• Chhatisgarh – Mitanin, Panchayat Ranking; RMAs; VHSCs.• Orissa – ASHAs; LLIN distribution; AYUSH doctors; GKSs.• Andamans – High salary for Specialists; RKS.

My understanding of UHC

• Every household has an entitlement to health• The entitlement is honoured by public

provisioning – general taxation and/or lifelong contribution from those who can afford to pay.

• It is not only medicalized care. • Provisioning of health care providers, hospital

beds, facilities as per standard is guaranteed for every geographical area – by public provisioning or through partnership.

International Experiences • Canada – publicly funded through universal single payer

public health insurance but is provided by both privately and publicly by hospitals and physicians operating for profit or not for profit health care provision units. Canada Health Act 1984.

• Thailand – Universal Health Care introduced in 2001. Contracted units of primary care. Hospital autonomy. Per capita allocation.

• Brazil – 1988 – Constitutional provision – universal right.

Public and contracted private services. Per capita allocation.

Universal Health Coverage - priority

I - Defining Entitlements – Normative funding.II - Human Development ThrustIII - Decentralized ManagementIV - Public provisioning and partnerships. V - Public Health thrust – preventive, curative.VI - Addressing human resourcesVII – Regulation and Quality Thrust

UHC – Essential framework

CRAFTING CREDIBLE PUBLIC SYSTEMS IN HEALTH

NRHM - MAKING MDGs ACHIEVEABLE