transformation of backward districts: challenges &...

Transformation of Backward

Districts: Challenges & Broad

Strategies

Ministry Of Health & Family Welfare1

Health Care Challenges

Indicator Global Best Kerala India

MMR (SRS 2011-13) 3 (Greece) 61 167

U5MR (SRS 2015) 3 (Finland) 13 43

IMR (SRS 2016) 2 (Japan) 10 34

NMR 1 (Singapore) 6 25

TFR (SRS 2015) 1.8 2.3

OOPE 8% (France, Cuba) 62%

Most of the backward districts have poor indicators compared to national average 3

Health Care ChallengesIndicator (in %) (NFHS-4) Kerala India Jharkhand*

Mothers who had at least

4 ANC visits 90.2 51.2 30.3

Pregnant women

who are anaemic 22.6 50.3 62.6

Institutional births 100 79 62

Children 12-23 months

fully immunized 82.1 62 62

Children breastfed

within one hour of birth64.3 41.6 33.2

IndicatorTamil Nadu Jharkhand

Rural Urban Rural Urban

OOPE per child birth (Rs)– Public 325 655 1249 1857

*Jharkhand has the highest number of backward districts 4

FATE OF 1000 NEWBORNS DEATHS CUMULATIVE &

INDICATOR

First 1 week 19

1- 4 weeks 6 more 25- Neonatal Mortality Rate

1 – 12 months

(next 48 weeks)

12 more 25+12= 37*

Infant Mortality

1- 5 years

(next 48 months)

6 more 37+6= 43

Under 5 Mortality

~45% U5MR in first week ~33% of U5 MR In <72 hours~18% of U5MR in 24 hours

*Data for 2015 is used as only IMR data for 2016 is available: Current

IMR is 34

5

BROAD STRATEGIES: KEY EFFECTIVE INTERVENTIONS

Neonatal Care (First 28 days) (high institutional deliveries –major

opportunity) - NMR/ U5MR is 25/43.

Labour Room Practices -Quality of Intra partum and Immediate Post

partum care

Breastfeeding (1st vaccine)- 13% of IMR can be prevented by correct Bf

Improve access to FRUs - Comprehensive Emergency Obstetric & Neonatal

Care services including access to C-section and safe blood eg: 80%

shortfall in UP despite NHM flexibility

RMNCH+ A –Continuum of care approach

Improved implementation of Rashtriya Bal Swasthya Karyakram- Early

Screening referrals to DEIC & intervention

Anemia Management (oral and injectable Iron, diet)- NIPI implementation

Active case finding and treatment compliance, ensuring private sector

participation, H1 schedule register for TB- major threat 6

KEY EFFECTIVE INTERVENTIONS

Ensure Comprehensive Primary Health Care - 12 essential services,

universal health check-up & Screening for NCDs and management, improve

usage of public health facilities

Transform Sub- Health Centres as Health & Wellness Centres with mid-level

providers (Nurses & Ayurveda doctors trained in public health & primary care

through Bridge Course)

Pay Special attention to NPCDCS and Mental Health Programmes

Strengthen DHs as Multi-specialty care and site for trainings

Strengthen monitoring- Use Data for evidence based action (HMIS/MCTS/

CRS/ NFHS -4)

Implement Public Health Interventions across sectors

7

Ensure essential Drugs & Diagnostics (Often through PPP) -free of cost

in public health facilities (Drugs account for 72% of OOPE on OP care).

Focus on Patient centric care- safety and with dignity- mera aspatal

Focus on Quality Assurance and Kayakalp

Focus on Health Systems integrated approach for human resource

Pay maximum importance to quality recruitment

Use mobile technology- RCH/MCTS portal, Kilkari for health

transformation, health promotion

Forge partnerships with NGOs and Private sector

KEY EFFECTIVE INTERVENTIONS

8

DMs oversee the design and implementation of District Health Action Plans

under the NHM. DPC and Zila Panchayat oversee health care delivery, monitor

the progress under the NHM, RSBY etc

Collector/ DM – Chairperson of the District Health Society and Rogi Kalyan

Samities of the District Hospitals- improve service quality

Use NHM flexibility- terms of engagement of HR-Align incentives (financial and

non-financial) to service providers to get desired behavior including quality of care,

design good contracts and monitor

Convergence & Co-ordination-Health outcomes depend on sectors outside core

health- nutrition, DWS, education, age at marriage, tobacco use, air pollution

Leadership, Improving Governance and Implementation

ROLES OF DISTRICT MAGISTRATES

9

Roles of District Magistrates: Addressing Gender Inequalities

1981 1991 2001 2011

962945

927 918

Child Sex Ratio

Census (1981-2011)

• Pre-conception and Pre-natal

Diagnostic techniques (Prohibition of

Sex Selection) Act, 1994 - enacted in

1996 and further amended in 2003

• Prohibits sex selection before and after

conception and imposes penalty

• Implementation though DCs & DMs who

are District Appropriate Authorities

10

Roles of District Magistrates in Immunization

• Identification of gaps and formulation of need based action plan - use of local

innovations

• Ensure enlisting of beneficiaries through head-count survey and its validation

• Ensure mapping of all high risk areas, remote hamlets, pockets of low

immunization coverage during micro-planning

• Facilitate rational deployment of ANMs as permanent measure & ensure

deployment to vacant sub-centres/urban areas during IMI

• Ensure proper social mobilization involving all stakeholders and sectors

• Lead from the front in dispelling myths/countering misinformation

• Ensure smooth and timely flow of allocated funds

• Ensure use of monitoring feedback for action

• Review the plan of integration of IMI sessions into Routine Imminization micro-

plans: critical activity for sustenance of gains11

Existing Output / process Possible Source

& Periodicity

Can be verified

by a survey

(quarterly)

NFHS once in

three years

% of ANC registered within 1st

trimester (within 12 weeks out of total

ANC registration (The indicator will

have impact on the gender equity as

well)

MCTS/RCH

portal -Monthly

Yes Yes

Proportion of registered pregnant

women receiving 4 more ANC

Checkups

HMIS - Monthly Yes Yes

% of High risk Pregnant women

delivered in the institution

MCTS/RCH

portal -Monthly

Yes Yes

Proposed Indicators: Antenatal Care

12


& Periodicity

Can be verified

by a survey

(quarterly)

NFHS once in

three years

Proportion of institutional

deliveries (of reported deliveries)

HMIS -

Monthly

Yes Yes

Proportion of home deliveries

attended by SBA trained (of

reported deliveries)

HMIS -

Monthly

Yes Yes

Proposed Indicators: ATTENDED BIRTHS

13


& Periodicity

Can be verified

by a survey

(quarterly)

NFHS once in

three years

Sex Ratio at birth CRS Yes Yes

Proposed Indicator: GENDER EQUALITY

14


& Periodicity

Can be verified

by a survey

(quarterly)

NFHS once in

three years

Percentage of newborns

breastfed within one hour of

birth

HMIS-

Monthly

Yes Yes

Underweight children: % of

severely underweight children

under 5 years

ICDS

Adequate Supplementary

nutrition among children 6-9

months

ICDS

Proposed Indicators: HEALTH AND NUTRITION

CONVERGENCE

15

Existing Output / process Possible Source &

Periodicity

Can be

verified by a

survey

(quarterly)

NFHS once in

three years

Percentage of

children fully

immunized (12-23

months)

MCTS/ RCH portal/

HMIS* - Quarterly

*If HMIS is using

indicator percentage of

children fully

immunized ( 9-11

months) may be used

Yes Yes (12-23

months)

Proposed Indicators: IMMUNIZATION

16


Periodicity

Can be verified

by a survey

(quarterly)

NFHS once in

three years

Proportion of Primary Health Centers

as per IPHS normsHMIS & Quarterly No No

Infrastructure: Functional FRUs

against required number of FRUs (1

per 5,00,000 population in plain terrain

and 1 per 3,00,000 for hills)

HMIS & Quarterly No No

Availability of specialist services:

Proportion of specialist services

available at Districts hospitals against

IPHS norms.

HMIS & Quarterly

Proposed Indicators: Good Governance Indicators

17


Periodicity

Can be verified

by a survey

(quarterly)

NFHS once in

three years

Infant Mortality ( per 1000 live

births)

Civil Registration

System /Quarterly

Yes Yes

Percentage of deaths due to diarrhea

among deaths reported (1month- 5

years ) reported

HMIS & Quarterly

available

No No

Percentage of deaths due to

Pneumonia among total deaths (1

month- 5 years ) reported

HMIS & Quarterly

available

No No

Proposed Indicators: HEALTH OUTCOMES

18


Periodicity

Can be

verified by a

survey

(quarterly)

NFHS once

in three

years

TB cases notified per 1,00,000

population

NIKSHAY- Quarterly

Treatment success rate among

notified TB patients

NIKSHAY- Quarterly

Proposed Indicators: HEALTH OUTCOMES

19

‘Women & children are not

dying because of a disease we

cannot treat. They are dying

because societies have yet to

make the decision that their

lives are worth saving ……’

20

FOR WOMEN, STILLBIRTHS, NEWBORNS, THE

TIME OF HIGHEST RISK IS THE SAME

1.2 million intrapartum

stillbirths

>1 million neonatal deaths

~113,000 maternal deaths

75% neonatal

deaths

Birth day

Birth is the time of greatest risk of

death and disability

Source: Lancet Every Newborn series,

paper2

Back to main presentation

21

Stunting in early childhood associated with cognitive and educational deficits in

late adolescence, current programmes targeted to height/weight related

consequences of malnutrition, ECCE- stimulation very critical


100 billion neurons with 100 trillion connections develop during the first

1000 days of life

22

Comparison of burden of TB, HIV and Malaria in India

Size of bubble proportionate to

deaths

Tuberculosis

HIV

Malaria

Disease DALY* Deaths

Malaria 287.18 562

HIV 520.21 67,000

TB 1258.37 4,80,000

*per 100,000 population

0

200

400

600

800

1000

1200

1400

1600

DA

LY

s p

er 1

00

,00

0 p

op

ula

tio

n


23

INDIA: RISING NCD BURDENS2011

(in Millions)

2030 (in Millions)

Diabetes 61 101

Hypertension 130 240

Tobacco Deaths 1+ 2+

PPYLL Due to CVD Deaths

(35-64 Yrs)*

9.2 (2000) 17.9

*Potentially Productive Years of Life Lost (PPYLL) Due To

Cardiovascular Deaths Occurring in The Age Group of 35-64 Years

India stands to lose $4.58 trillion between 2012 and 2030 due to non-communicable

diseases- World Economic Forum Back to main presentation

25

What risk factors drive the most death and disability combined?

GBD, 2015


26

Sonbhadra (UP) Performance of Public Facilities – OPD(2016- 2017)

P

e

r

f

o

r

m

a

n

c

e

Facility Type CHC PHC SHC

Total no. of public

facilities6 29 173

No. reporting nil

performance 0 0 37

Max to Min Ratio 3 34 1485

Maximum 65534

(Dudhhi)

47914

(Kakrahi)

2969

(Nadhira)

Minimum 19916

(Babhani)

1419

(Bijpur)

2

(Chanchikala)

No. of facilities by

performance (FY

2016-17)

1 to 1200 0 0 1341201 to 6000 0 14 26001 to 12000 0 9 0> 12000 6 6 0


27


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Comprehensive Primary Health Care- Package of Services

1. Care in pregnancy and child-birth.

2. Neonatal and infant health care services

3. Childhood and adolescent health care services.

4. Family planning, Contraceptive services and Other Reproductive Health Care services

5. Management of Communicable diseases: National Health Programmes

6. General Out-patient care for acute simple illnesses and minor ailments

7. Screening and Management of Non-Communicable diseases

8. Screening and Basic management of Mental health ailments

9. Care for Common Ophthalmic and ENT problems

10. Basic Dental health care

11. Elderly and palliative health care services

12. Trauma Care (that can be managed at this level) and Emergency Medical services


30

Under 5 Deaths: Causes

Source- Cause of Death Report, RGI (2010-13)

Estimated 10.8 lakh U5 deaths

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