keynote address: stewardship and governance in health systems with special reference to the national...
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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
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