NRHM – REINVENTING SYSTEMS  Stewardship and Governance in Health Amarjeet Sinha
Understanding India <ul><li>Over a billion people in over a million places. </li></ul><ul><li>Persistence of poverty and u...
The Health Scenario <ul><li>Multiple burden of disease – communicable, non-communicable; unattended morbidities. </li></ul...
Public Policy -Getting basics right  <ul><li>Theory without practice is as dangerous as practice without theory </li></ul>...
NRHM – What is different……… <ul><li>A true partnership with States. </li></ul><ul><li>Space for innovations. </li></ul><ul...
<ul><li>NRHM – ALMA ATA + </li></ul>PHC Alma Ata Approach Health Education Nutrition & Food Security Safe Water & Sanitati...
HUMAN RESOURCES - Community Workers. - Nurses and Doctors. - Public Health Cadre. - Multi skilling Specilaists. PRIMARY HE...
National Rural Health Mission launched in April, 2005 <ul><li>Rejuvenate the Health delivery System </li></ul><ul><li>Univ...
<ul><li>NRHM – Main Approaches </li></ul>COMMUNITIZE 1.   Hospital Management Committee/ PRIs at all levels 2.  Untied gra...
BLOCK LEVEL HOSPITAL 30-40 Villages Strengthen Ambulance/ transport Services Increase availability of Nurses Provide Telep...
What is the Change ? <ul><li>Health – a priority in States as never before. </li></ul><ul><li>Public health thrust recogni...
Key New Developments <ul><li>Multi-skilling of Doctors – LSAS, EmOC. </li></ul><ul><li>Emergency Transport – Diversity of ...
KEY STATE LEVEL HEALTH SYSTEM INSTITUTIONS & FUNCTIONS <ul><li>Directorate of Tertiary  </li></ul><ul><li>Care/Med. Edn. <...
Emerging Stewardship and Governance Challenges   <ul><li>Building Capacity for Public Health. </li></ul><ul><li>Managing h...
Managing for performance <ul><li>Appropriate skills </li></ul><ul><li>Training and learning </li></ul><ul><li>Leadership a...
MANAGEMENT OF HEALTH SYSTEM TASKS LEVEL TEAM Supervision of services Training of community Survey and mobilization Distrib...
BUILDING CAPACITY THROUGH RESOURCE GROUPS TASKS LEVEL TEAM Training of PRIs/CBOs Surveys/MIS Training ASHA/ANM Distributio...
COMMUNITIZATION OF HEALTH CARE TASKS LEVEL TEAM Community action Survey/Support Planning/implementn Village Health & Sanit...
The impact of NRHM  <ul><li>MMR significantly down – 450 to 230 as per UN Reports; 301 to 215-220 ( approx.) – SRS.  </li>...
NRHM – Institutional strengthening <ul><li>VHSc, PRIs, RKSs, DHMs, SHMs, MSG. </li></ul><ul><li>Joint Bank Accounts for VH...
NRHM – System strengthening <ul><li>Financial Management – FMR, Audit, Managers. </li></ul><ul><li>Programme Management – ...
NRHM – Fostering Innovations <ul><li>Decentralizing thought and action. </li></ul><ul><li>Respecting local thought and act...
Examples of Innovations   <ul><li>Making PHCs 24X7 in Tamil Nadu – 3 Nurse model. </li></ul><ul><li>Assam’s initiative – B...
My understanding of UHC <ul><li>Every household has an entitlement to health </li></ul><ul><li>The entitlement is honoured...
International Experiences  <ul><li>Canada – publicly funded through universal single payer public health insurance but is ...
Universal Health Coverage - priority <ul><li>I -  Defining Entitlements – Normative funding. </li></ul><ul><li>II - Human ...
UHC – Essential framework
CRAFTING CREDIBLE PUBLIC SYSTEMS IN HEALTH NRHM - MAKING MDGs ACHIEVEABLE
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Keynote Address: Stewardship and Governance in Health Systems with special reference to the National Rural Health Mission.-Amarjeet Sinha

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

  1. 1. NRHM – REINVENTING SYSTEMS Stewardship and Governance in Health Amarjeet Sinha
  2. 2. Understanding India <ul><li>Over a billion people in over a million places. </li></ul><ul><li>Persistence of poverty and under nutrition. </li></ul><ul><li>Low public exp./high out of pocket on health. </li></ul><ul><li>Regional disparities – Kerala/TN & Orissa/Bihar. </li></ul><ul><li>Large unregulated private sector – need to engage with not for profit and for profit. </li></ul><ul><li>Medicalized versus health – water, sanitation. </li></ul><ul><li>Medical – para medical divide. </li></ul><ul><li>Human resource challenges - urban - rural. </li></ul>
  3. 3. The Health Scenario <ul><li>Multiple burden of disease – communicable, non-communicable; unattended morbidities. </li></ul><ul><li>High Child and maternal deaths. </li></ul><ul><li>50% under- nourished and anemic women and children – very little improvement. </li></ul><ul><li>Water and sanitation challenges remain. </li></ul><ul><li>Food security is an issue. </li></ul><ul><li>Malaria, dengue, chikanguniya – on the rise. </li></ul><ul><li>Public health regulation – very weak. </li></ul><ul><li>High TFR in UP, Bihar, MP, Rajasthan, Jharkhand. </li></ul>
  4. 4. Public Policy -Getting basics right <ul><li>Theory without practice is as dangerous as practice without theory </li></ul><ul><li>Begin from the problem; do not impose a solution without looking at the problem. </li></ul><ul><li>I don’t care what colour is the cat, as long as it catches mice – pragmatic, evidence based, not ideological!!! </li></ul><ul><li>The map is not the territory!!! </li></ul><ul><li>Samakhya – Dialogue of equals !!! </li></ul><ul><li>If you do not do what you have to do, you will never be able to do what you want to do !!!! </li></ul>
  5. 5. NRHM – What is different……… <ul><li>A true partnership with States. </li></ul><ul><li>Space for innovations. </li></ul><ul><li>Distrust to trust. </li></ul><ul><li>Community institutions as focus. </li></ul><ul><li>A worker, an institution and an event in every village – ASHA, VH&SC, VHND. </li></ul><ul><li>Public health focus – addressing local specific mortality and morbidity. </li></ul><ul><li>Building capacities for local action. </li></ul><ul><li>Recognizing the need for management skills. </li></ul>
  6. 6. <ul><li>NRHM – ALMA ATA + </li></ul>PHC Alma Ata Approach Health Education Nutrition & Food Security Safe Water & Sanitation Maternal and Child Health Family Planning Immunization against Infectious Disease Appropriate Treatment of Common diseases And injuries Prevention & control of locally endemic diseases Provision of essential drugs
  7. 7. 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 HEALTH 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. Improving public health
  8. 8. National Rural Health Mission launched in April, 2005 <ul><li>Rejuvenate the Health delivery System </li></ul><ul><li>Universal Health Care </li></ul><ul><li>Access </li></ul><ul><ul><li>Affordability </li></ul></ul><ul><ul><li>Equity </li></ul></ul><ul><ul><li>Quality </li></ul></ul><ul><ul><li>Reduce IMR, MMR,TFR </li></ul></ul><ul><ul><li>Improve Disease control </li></ul></ul>
  9. 9. <ul><li>NRHM – Main Approaches </li></ul>COMMUNITIZE 1. Hospital Management Committee/ PRIs at all levels 2. Untied grants to community/ PRI Bodies 3. Funds, functions & functionaries to local community organizations 4. Decentralized planning, 5. Intersectoral Convergence IMPROVED MANAGEMENT THROUGH CAPACITY 1. Block & District Health Office with management skills 2. NGOs in capacity building 3. NHSRC / SHSRC / DRG / BRG 4. Continuous skill development support FLEXIBLE FINANCING 1. Untied grants to institutions 2. NGOs for public Health goals 3. NGOs as implementers 4. Risk Pooling – money follows patient 5. More resources for more reforms INNOVATION IN HUMAN RESOURCE MANAGEMENT 1. More Nurses – local Resident criteria 2. 24 X 7 emergencies by Nurses at PHC. AYUSH 3. 24 x 7 medical emergency at CHC 4. Multi skilling MONITOR, PROGRESS AGAINST STANDARDS 1. Setting IPHS Standards 2. Facility Surveys 3. Independent Monitoring Committees at Block, District & State levels
  10. 10. BLOCK LEVEL HOSPITAL 30-40 Villages Strengthen Ambulance/ transport Services Increase availability of Nurses Provide Telephones Encourage fixed day clinics Ambulance Telephone Obstetric/Surgical Medical Emergencies 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 Day Drug 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
  11. 11. What is the Change ? <ul><li>Health – a priority in States as never before. </li></ul><ul><li>Public health thrust recognized. </li></ul><ul><li>NRHM – A platform for innovations. </li></ul><ul><li>NRHM – A Framework for decentralization. </li></ul><ul><li>Human Resource as priority. </li></ul><ul><li>Community Worker – connecting households </li></ul><ul><li>A statement that public systems can deliver. </li></ul><ul><li>Managers of the system – professional skills. </li></ul>
  12. 12. Key New Developments <ul><li>Multi-skilling of Doctors – LSAS, EmOC. </li></ul><ul><li>Emergency Transport – Diversity of models. </li></ul><ul><li>Mobile Medical Units. </li></ul><ul><li>Local Criteria in selection. </li></ul><ul><li>Developing locals as health workers. </li></ul><ul><li>Incentives for remote areas. </li></ul><ul><li>Primacy to nursing – over 75,000 added. </li></ul><ul><li>Over 800,000 ASHAs – connecting households </li></ul><ul><li>Over 15,000 MBBS Doctors, Specialists, AYUSH. </li></ul><ul><li>Untied Grants to institutions – Guarantee services. </li></ul><ul><li>Community Monitoring – AGCA; ASHA Mentoring; MSG. </li></ul><ul><li>Enhanced drug Budgets. </li></ul><ul><li>Demand generation and supply side strengthening – partnerships. </li></ul>
  13. 13. KEY STATE LEVEL HEALTH SYSTEM INSTITUTIONS & FUNCTIONS <ul><li>Directorate of Tertiary </li></ul><ul><li>Care/Med. Edn. </li></ul><ul><li>Medical/Nursing/ Paramedical </li></ul><ul><li>Education </li></ul><ul><li>Training and Skill Development </li></ul>The Key Health System Institutions (Admn Div., Nursing Div. and Financing Div. along with each directorate) <ul><li>Directorate of Hospital </li></ul><ul><li>Services </li></ul><ul><li>Hospital Services </li></ul><ul><li>(District/Sub-dt. Hospitals) </li></ul><ul><li>Emergency Services </li></ul>Directorate of Public Health Primary Health Care (up to Block Level) Disease control Programmes RCH Programmes: SIHFW In service skills Development Pre-service training programmes <ul><li>State PMU: </li></ul><ul><li>HMIS & Evaluation: </li></ul><ul><li>Extra-Budgetary </li></ul><ul><li>Fund Flows </li></ul><ul><li>HR : contractual </li></ul><ul><li>staff. </li></ul><ul><li>Addl. Capacity for </li></ul><ul><li>Programmes </li></ul><ul><li>Medical Services </li></ul><ul><li>Corporation </li></ul><ul><li>Procurement, </li></ul><ul><li>Logistics </li></ul><ul><li>Infrastructure </li></ul><ul><li>Development </li></ul>Health Regulation Pvt. Sector; Food & Drugs PPPs, Insurance AYUSH <ul><li>SHSRC </li></ul><ul><li>State/Dt. Planning :- Pgm. </li></ul><ul><li>Design, Financing, HR, </li></ul><ul><li>Governance, HMIS </li></ul><ul><li>Community Processes </li></ul>
  14. 14. Emerging Stewardship and Governance Challenges <ul><li>Building Capacity for Public Health. </li></ul><ul><li>Managing higher financial resources. </li></ul><ul><li>Capacity for decentralization. </li></ul><ul><li>Evidence based approach. </li></ul><ul><li>Community Monitoring – Accountability. </li></ul><ul><li>A reliable, timely, facility specific, HMIS. </li></ul><ul><li>Institution – specific autonomy. </li></ul><ul><li>Transparent human resource management. </li></ul>
  15. 15. Managing for performance <ul><li>Appropriate skills </li></ul><ul><li>Training and learning </li></ul><ul><li>Leadership and entrepreneurship </li></ul><ul><li>Satisfactory remuneration </li></ul><ul><li>Work environment </li></ul><ul><li>Systems support </li></ul><ul><li>Numeric adequacy </li></ul><ul><li>Skill mix </li></ul><ul><li>Social outreach </li></ul>Human resource actions Competence: Training and learning Coverage: Social and physical Workforce objectives Quality And responsiveness Equitable access Health outcomes Health system performance Motivation: Systems and support Efficiency and effectiveness Health of the population
  16. 16. MANAGEMENT OF HEALTH SYSTEM TASKS LEVEL TEAM Supervision of services Training of community Survey and mobilization Distribution of drugs Monitoring/Reporting Block Level Health Team Block Medical Officer Block Resource Group Accountant Data Entry Assistant Store Keeper Planning and MIS Capacity building Mapping NGOs Financial Management Procurement/Stores Technical/Community Planning and MIS Capacity building Financial Management Procurement/Stores Technical/Community District Level Health Team DM – DMHO Mgt. Expt. As ADHMO Finance/Data/Proc. Tech./NGO/Community State Level Health Team Mission Director Coordinators – Technical, Financial, MIS, M&E, Gender, NGO, Procurement,
  17. 17. BUILDING CAPACITY THROUGH RESOURCE GROUPS TASKS LEVEL TEAM Training of PRIs/CBOs Surveys/MIS Training ASHA/ANM Distribution/FM BLOCK LEVEL Block Health Office Block Resource Team RPs Surveys/MIS/NGO Procurement/Data Training/M&E Financial Mgt. Studies/Supervision Procurement/MIS Training/Planning FM/ M&E/NGOs DISTRICT LEVEL District Resource Group; PMU; Specially recruited skills ; DHM STATE LEVEL State level Mission SIHFW/Instns./NGOs Resource Centre Planning/supervision MIS/M&E/Proc./FM NGOs/Community Technical Skills NATIONAL LEVEL NHSRC/NIHFW MoHFW Institutions
  18. 18. COMMUNITIZATION OF HEALTH CARE TASKS LEVEL TEAM Community action Survey/Support Planning/implementn Village Health & Sanitation Committee ASHA/AWW/PRI SHG/CBO NGOs Planning/Survey Community action Implementation Planning/ Support Supervision Community action Sub Health Centre level, Gram Panchayat Samiti ANM/MPW PRI/NGO Women’s groups PHC level cluster level Committee PHC MO/Para Medics NGO/PRI Women’s Groups Planning/Implementation/ accountability Public Hearings Health Camps CHC/Block PHC/ BMO level Panchayat Samiti/ RKS BHO; RKS of CHC; Panchayat Samiti NGO/CBOs/ SHGs Planning/ M&E/ Supervision Accountability District level Health Mission under the Zila Parishad Zila Parishad; DM/CEO/DMHO PMU/NGOs
  19. 19. The impact of NRHM <ul><li>MMR significantly down – 450 to 230 as per UN Reports; 301 to 215-220 ( approx.) – SRS. </li></ul><ul><li>IMR decline – 60 in 2004; 53 in 2008; 50 now? </li></ul><ul><li>TFR steadily declining – 2.9 in 05 to 2.6 in 2008. </li></ul><ul><li>Institutional deliveries – 41% to 73% </li></ul><ul><li>TB, Malaria, NPCB, Surveillance better. </li></ul><ul><li>Substantial addition of human resources. </li></ul><ul><li>Infrastructure – more and better managed. </li></ul><ul><li>Doctors, drugs and diagnostics – OPD, IPD. </li></ul>
  20. 20. NRHM – Institutional strengthening <ul><li>VHSc, PRIs, RKSs, DHMs, SHMs, MSG. </li></ul><ul><li>Joint Bank Accounts for VHSC and Sub Centres. </li></ul><ul><li>Registered Rogi Kalyan Samitis at PHC and above – legal entity – opportunity for autonomy. </li></ul><ul><li>Flexibility and adequacy of funding with accountability framework to ensure public action. </li></ul><ul><li>Decentralized planning and implementation. </li></ul><ul><li>States, districts, blocks, villages deciding priority for public health action. </li></ul><ul><li>System for procurement and logistics – TNMSC. </li></ul><ul><li>Improving Human Resource Management. </li></ul><ul><li>HMIS – web enabled monitoring system. </li></ul>
  21. 21. NRHM – System strengthening <ul><li>Financial Management – FMR, Audit, Managers. </li></ul><ul><li>Programme Management – SPMU, DPMU, BPMU. </li></ul><ul><li>Data Management – HMIS, Facility performance. </li></ul><ul><li>Development of Standards – IPHS, NABH, ISO. </li></ul><ul><li>Capacity development for public health – public health management master’s (PHFI) and diploma (PHRN – IGNOU). </li></ul><ul><li>Family Medicine programme – CMC Vellore </li></ul><ul><li>Professional Development Courses – NIHFW, SIHFWs </li></ul><ul><li>Accountability system – CRMs, Concurrent Evaluation, Community Monitoring, Performance Audit of CAG. </li></ul>
  22. 22. NRHM – Fostering Innovations <ul><li>Decentralizing thought and action. </li></ul><ul><li>Respecting local thought and action. </li></ul><ul><li>Providing platform for sharing and learning. </li></ul><ul><li>Intensive engagement in capacity development at all levels. </li></ul><ul><li>Building systems that foster innovations. </li></ul><ul><li>Analytical feedback to States. </li></ul><ul><li>Crafting convergent and credible platforms at all levels of care. </li></ul><ul><li>PUTTING PEOPLE’S HEALTH IN PEOPLE’S HANDS – TAKING CHARGE!!!! </li></ul>
  23. 23. Examples of Innovations <ul><li>Making PHCs 24X7 in Tamil Nadu – 3 Nurse model. </li></ul><ul><li>Assam’s initiative – Boat Clinics, Evening OPDs, ASHA. </li></ul><ul><li>Rajasthan’s initiative – RRHS; IEC; CMJRK;MMUs; SNCUs. </li></ul><ul><li>MP’s initiative – Janani Express, HSC Delivery, SNCUs. </li></ul><ul><li>Haryana’s initiative – Free drugs, 102; surgery package. </li></ul><ul><li>Gujarat’s initiative – Chiranjeevi, 108, NABH; Managers. </li></ul><ul><li>Kerala’s initiative – KMSC, Ban private practice; Quality. </li></ul><ul><li>Bihar – Block pooling; PPPs – Diagnostics. </li></ul><ul><li>Chhatisgarh – Mitanin, Panchayat Ranking; RMAs; VHSCs. </li></ul><ul><li>Orissa – ASHAs; LLIN distribution; AYUSH doctors; GKSs. </li></ul><ul><li>Andamans – High salary for Specialists; RKS. </li></ul>
  24. 24. My understanding of UHC <ul><li>Every household has an entitlement to health </li></ul><ul><li>The entitlement is honoured by public provisioning – general taxation and/or lifelong contribution from those who can afford to pay. </li></ul><ul><li>It is not only medicalized care. </li></ul><ul><li>Provisioning of health care providers, hospital beds, facilities as per standard is guaranteed for every geographical area – by public provisioning or through partnership. </li></ul>
  25. 25. International Experiences <ul><li>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. </li></ul><ul><li>Thailand – Universal Health Care introduced in 2001. Contracted units of primary care. Hospital autonomy. Per capita allocation. </li></ul><ul><li>Brazil – 1988 – Constitutional provision – universal right. Public and contracted private services. Per capita allocation. </li></ul>
  26. 26. Universal Health Coverage - priority <ul><li>I - Defining Entitlements – Normative funding. </li></ul><ul><li>II - Human Development Thrust </li></ul><ul><li>III - Decentralized Management </li></ul><ul><li>IV - Public provisioning and partnerships. </li></ul><ul><li>V - Public Health thrust – preventive, curative. </li></ul><ul><li>VI - Addressing human resources </li></ul><ul><li>VII – Regulation and Quality Thrust </li></ul>
  27. 27. UHC – Essential framework
  28. 28. CRAFTING CREDIBLE PUBLIC SYSTEMS IN HEALTH NRHM - MAKING MDGs ACHIEVEABLE

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