District Health Action Plan
DR HARASHISH JINDAL
• What is Programme Implementation Plan(PIP)?
• What is District Health Action Plan(DHAP)?
• Preparation of DHAP
• Structure of DHAP
• Components of DHAP
• Budgeting Norms
• Origin in National Rural Health Mission(NRHM) which was
launched on 12th April 2005
• One of main core strategy was preparation and
implementation of intersectoral district health action plan by
district health mission including drinking water, sanitation,
hygiene and nutrition.
What is a Programme Implementation Plan?
• Document prepared by states, which helps in identifying and
quantifying their targets required for implementation of the
programme for the proposed year.
• Finalized by National Programme Coordination Committee
meeting for administrative approval .
• After approval, budgets are sanctioned, becomes an official
What is a DHAP?
• Guiding document appraised and approved at State level for
implementation, monitoring & evaluation of NRHM activities
in the district.
• Makes decentralized programme management more responsive
to the health care needs of local community.
• A step towards ultimate communitisation - a hallmark of
Need for DHAP
• Translation of a “new” health policy statement into a plan of
• Translation of a “master plan” such as a national plan into a
• Re-planning on the basis of an already existing plan, for the
purpose of reviewing existing health problems and needs, and
rendering services which are more effective and efficient.
• Meeting the necessary standards and achieving the set
• Economizing on available resources.
• Ensuring coordinated effort and action.
Preparation of DHAP
• The District Health Mission has been entrusted with the
responsibility of steering formulation and ensuring
implementation of the plan.
– headed by the Chairperson, Zila Parishad.
– the District Collector as the Co-Chair
– Chief Medical Officer as the Member Secretary.
• To support the District Health Mission, an integrated District
Health Society (DHS) has been constituted.
– to provide a platform where the three arms of governance – ZP, ULBs
and district health administration and district programme managers of
NRHM sectors get together to decide on health issues of the district and
delineate their mutual roles and responsibilities.
The Planning Process
• The NRHM had a seven year time frame (2005-2012).The
Perspective Plan would be a 7 year plan outlining the year wise
resource and activity needs of the district.
• The annual plan will be based on resource availability and a
• requires setting up of planning teams and committees at various
– Village level
– Gram Panchayat (SC),
– PHC (Cluster level),
– CHC/Block level
– District level.
• At Village, PHC and Block levels, broadly representative
committees would perform both planning and ongoing monitoring
ASHA, the Aanganwadi the Panchayat representative, the SHG
leader and local CBO :responsible for the household survey, the
Village Health Register and the Village Health Plan.
Technical Assistance for DHAP
• State should harness all technical resources including
development partners, department of community medicine in
medical colleges, NGOs with expertise in this area etc.
• The State Health Resource Center (SHRC) would finalize
survey formats and formats for preparation of plans at various
• District Plan Appraisal Team :10-15 members, under the SHRC
for appraisal of the Draft District Plan for checking Quality,
Standards, normative criterions etc before it receives the formal
Framework for DHAP
• Resources – health human power, logistics and supplies , community
resources and financial resources, voluntary sector health resources.
• Access to services –public and private services and informal health
care services, levels of integration of services within public health
• Utilisation of services –outcomes, continuity of care; factors
responsible for possible low utilization of public health system
• Quality of Care –technical competence, interpersonal
communication, client satisfaction, client participation in
management, accountability and redressal mechanisms.
• Socio-epidemiological situation- local morbidity profile,
major communicable diseases and transmission patterns,
health needs of special social groups.
• Community needs, perceptions and economic capacities,
PRI involvement in health, existing community organizations
and modes of involvement in health.
Framework for DHAP
Components of the District
• It was envisaged that this plan would be a holistic plan but to
facilitate fund release and for monitoring, the Plan may be
divided into the following components:
a. Interventions under NRHM
b. RCH II
c. Strengthening of Immunisation
d. Disease Control / Surveillance Programmes such as
NVBDCP , RNTCP, NPCB, IDD ,NLEP and IDSP
e. Intersectoral convergence activities including Nutrition,
Safe Drinking Water etc
• Profile of the district in terms of its
– background characteristics,
– health facilities (both public and private),
– functionality of health facilities,
– coverage of ICDS programmes,
– availability of elected representatives of Panchayati Raj
– presence of NGO’s & CBO’s
which helps to understand the district better and also to identify the
constraints particularly in terms of size of villages, access to
• Distribution of Villages by population size: Implications on
how to organize services in outreach, assignment of villages to
the additional ANMs and ASHA’s, addressing logistics issues
for outreach services etc.
• Economic classification especially BPL distribution will help
define estimations of JSY clients and also design interventions
based on alternative health financing mechanisms.
• Literacy-male to female: Will help in designing of appropriate
communication activities using more visuals than written
• Sex Ratio: Improve PNDT operationalization
Public health facilities and
functionality of facilities
• Helps to know the different types of public health institutions
in the district.
• How many institutions are actually functional in terms of
availability of infrastructure and critical staff position.
• Percentage of facilities that are functional - analyze by categories
• Based on the spatial distribution of facilities and availability of staff,
prioritize institutions for strengthening for providing services.
• Issues of road connectivity with such institutions and the population
• Help identifying blocks in need of additional inputs for making
services available to the community or where demand side
interventions such as ASHAs will be needed on priority.
• As staff transfers are frequent and non-availability of critical staff
results in disruption in services, the analysis should identify such
recurrent problems & discuss the probable solutions in block
• Streamlined logistics systems helps provide medicines,
contraceptives, vaccines and other consumables to service
providers in adequate quantity at right time and place and also
help to reduce wastage.
• Address any out of stock situation: facilitate adequate buffer
• Need for use of management techniques for logistics.
• The actions to be taken based on feedback reports of the
• Poor storage of vaccines: Provision of proper cold chain
• For capacity building of the functionaries, it is imperative to
have good training infrastructure, competent staff members at
the training institutions and necessary teaching aids.
• These institutions could be an ANM training centre, District
training team or centre or even the regional training outfits,
Divisional Training centres etc.
• Private sector nursing training institutions should also be
considered in this analysis.
• Assess availability of resources to undertake demand
generation activities in the district??
• Hence for assessing BCC infrastructure in the district
following information has to be collected.
• Identifies the areas of strengthening will be useful in planning
for necessary inputs
Private Health Facilities and
Type of Facilities
• With the government seeking public-private partnership
through its programmes, it becomes more important.
• Depending on the motivation of the private provider to be a
partner in the PPP mechanism, appropriate strategies and
interventions could be planned on the basis of facilities and
expertise of the institution.
• Critical programme from the convergence point of view.
• Complementary nature of job functions of ICDS worker at the
village level with that of the ASHA/ANM strongly vouch for
convergence of services and assures better accessibility to
health care services.
• When district and block level consultation meetings are
planned, it is important to ensure the presence of ICDS
Elected Representatives of
• Sets out a process of communitization.
• Information from this matrix will
– help to plan capacity development interventions for PRIs,
– help the planning team to design local area -specific
interventions with PRI,
• It is possible to expand some earmarked resources at the level
NGO and CBO
• In the RCH programmes, mother and field NGOs are
supported to organise service delivery activities in the district.
• The important role of non-governmental and community based
organizations in community mobilization and ensuring their
involvement is a proven testimony.
• NRHM strongly advocates their involvement and ownership,
as essential pre-requisites for achieving the best results.
• Potiental for enhancing service access in under covered
blocks/ sectors or even cluster of villages or working on the
Analysis of Key Health
• It brings out an overview of health and RCH of the district.
• Idea of the utilization pattern among the different categories
and will provide necessary inputs as to what needs to be done
to enhance services.
• Common diseases in the area, endemic pockets, and
seasonality of diseases will be compiled.
• Identify blocks with poor or inadequate utilization and reasons
there of .
• Summarize the reasons of poor utilization
• Identify the reasons and make a note such as staff vacancies
Examine the performance on the following indicators of
• Percent of pregnant women who availed complete package of
• Percentage of institutional deliveries
• Percentage of safe deliveries
• Percentage of C-section deliveries
• Percentage of Maternal deaths audited
• Maternal mortality
• Maternal death audit esp.verbal autopsies
• The unmet need for family planning will help us in estimating the
potential users who need to be identified, counseled and provided
services of their choice.
• While analyzing these indicators, also look into the reasons for
discontinuation or non-use among current non-users and highlight
the major findings.
• Any failures due to sterilization, deaths and major complications
(requiring hospitalization) should be reviewed.
• If there are too many failures occurring in a particular block, then
reasons in terms of skills of surgeons providing sterilization services
and quality issues will have to be looked into and proper capacity
building interventions will have to be planned.
RNTCP, NVBDCP, NPCB,
IDSP, NLEP & NIDDCP
• Unlike RCH indicators, survey data on health is not available
and hence will have to be compiled from district service
• The national monitoring of malaria and tuberculosis has
confined to a few critical indicators that are compiled from the
• Information on these indicators will have to be put together
and along with it, other health Problems in the area will have
to be stated block-wise
Locally endemic diseases in the
• The information could be obtained from the hospital MIS or
through surveys/ research. Any research reports available
should also be reviewed.
• The distribution of the diseases as per blocks or cluster of
villages (in cases of chemical contamination of water sources)
should be mapped.
Interventions under NRHM
• Analyze the reasons for low performance such as in case of
ASHAs, or disbursements for JSYs or registration of RKS etc.
• Propose appropriate interventions
Block Level and Stakeholders
• To actively engage a wide range of stakeholders from the
community, including the panchayats, in the planning process
• To identify local issues and concerns as well as vulnerable groups
and areas to reach consensus on feasible solutions/intervention
• To take advantage of opportunities for inter sectoral convergence
that exist at the block level in making the planning process more
holistic in nature
• To identify priorities at the grassroots and carve out roles and
responsibilities at the panchayat and block levels in design and
implementation of DHAPs for greater ownership and needbased
implementation of NRHM
Block Level and Stakeholders
• The timeframe is likely to be about a month and a half for the
full process. The preparatory processes -a month. The next 15
days - actual consultations in each block of the district, set
priorities and finalise outcome of the consultation for each
• A facilitator agency/NGO is needed to carry out the process.
• Criteria for identifying the agency:
– Involved with the development/social sector
– Familiar with health issues, government programmes and
schemes and has an understanding of the field/community
– Has staff (both men and women) with analysis and
documentation skills required to facilitate the process and
to deliver in a timely manner
Step I(Problem identification)
• Involve MNGOs/FNGOs in the process of holding block level
• Orient Gram panchayat representatives on the process and
collection of village/ GP level information prior to the
• Share and explain the use of the indicative checklist to collect GP
• Service side information to be collected and gaps identified by the
• If possible, complement the information collected from the GPs
with block/sub-centre level service data available at the facilities
Step II(Consolidate and analysis)
• Following the collection of GP level information, the
facilitating agency/NGO to hold a meeting to validate the
information (optional, to be held only if possible)
• Facilitating agency/NGO to consolidate the information
collected and prepare note for circulation based on the
indicative format at checklist 2.
• The panchayats and the service providers to undertake priority
setting during the consultation based on the consolidated
picture presented by the facilitating agency/NGO
• The task of formulating DHAP objectives should take into
account the state NRHM PIP and the Memorandum of
Understanding between the state and the national government.
• Inputs from the situational analysis conducted and the block-
level consultations guide in deciding what a district can
achieve pragmatically, in the given time frame.
• SMART approach.
The District Planning Workshop
• Objective :
– To review and set objectives of the DHAP;
– To assess appropriateness and adequacy of suggested
strategic interventions/and activities to meet the objectives
of the DHAP;
• District Collector– Chair for the workshop
• CEO of the Zilla Parishad
• NRHM Mission Director
• Members of the District Mission
• PRI representatives (10 at least 50 percent should be women)
• District level officials from Health and Family Welfare
• District level officials from Line departments i.e. WCD, Water
• Block Level Departmental Functionaries (especially from
WCD, Health and Water Sanitation)
• Networks of the Private service providers
• A management tool to plot their various main and sub-
activities at the beginning of the year.
• Once the activities have been planned, DPM would then need
to see how they have been adhering to the planned programs,
where the pitfalls are, the reasons why they lag behind the time
schedule and the mid-course action required to correct them.
• two model Work Plans –
– The month-wise plan is for one year plans
– The quarterly work plan is for two year.
• Activities put in a matrix form wherein the time of initiation of
the activity, the tentative duration of implementation and
completion should be specified for each of them and more
importantly, persons/agency responsible should be explicitly
• Scheduling of activities in a systematic way .
• All activities whether costed or not costed should be included
in the Workplan.
• This matrix will facilitate in not only providing information on
when the activities have to be initiated and completed but can
be effectively used for tracking the status of each of the
defined activities along with monthly monitoring.
Monitoring & Evaluation
• State PIP document sets the input and process indicators and
has decided on the frequency of monitoring.
• Performance evaluation mechanism will mostly rely on
baseline, concurrent, mid-term and end-line surveys.
• Both internal and external as government and non-government
agencies will be involved.
• Qualitative studies and community reporting will be done to
supplement impact assessment studies.
• Evaluation system rely on District surveys.
NHM PIP Guidelines 2014-17(Background)
State Programme Implementation Plans (PIPs) will consist of the
following five parts:
– PART I: RMNCH + A (NRHM + RCH including immunization)
– PART II: NUHM Flexipool;
– PART III: Flexipool for Disease Control Programmes;
– PART IV:Flexipool for non-communicable diseases including
injury and trauma;
– PART V: Infrastructure Maintenance.
There will be a separate financial envelope tied to Parts I to IV
within which every State will have the flexibility to allocate funds
across different strategies/ activities in line with local conditions
and within broad national priorities.
• At least 70% of funds should be allocated to districts. High priority
districts to be allocated 30% more (vis-a-vis the population) funds.
• Tribal population / areas and vulnerable groups to receive special
• Construction / upgrading of facilities should along with other
parameters be determined by time to primary health care i.e. no
more than 30 minutes of walking distance, and secondary care
services including C-section and blood transfusion are available
within two hours of any habitation, with an assured referral transport
system connecting the two.
• In hard to reach areas, Mobile Medical Units (MMUs) should be
used to provide primary healthcare services on a regular basis.
• Not more than 33%of total state resource envelope should be
allocated for infrastructure in EAG states; for other states, the
corresponding figure is 25%.
• Prioritise facilities with higher caseloads (deliveries,
OPD/OPD services) for further development; all others should
maintain or redeploy existing staff.
• Annual untied amount to be doubled for CHCs and District
Hospitals; but this should be reallocated based on need/case
• Up to 5% of state resource envelope may be allocated towards
• No more than 5% of the total state resource envelope should
be allocated for NGOs supporting service delivery; this may
overlap with other activities such as capacity building.
• Programme management costs should not account for more
than 5.5% of the total annual work plan; however in small
states and union territories this may increase to no more than
• For technical assistance at the State and District level, up to
2% of the state annual work plan may be allocated.
• The cost of monitoring including MIS should be no more than
1% of total NHM funds.
• Up to 10% of the total NHM resource envelope may be used to
fund innovations at the state level either
– by establishing new centres and/or purchase of services
from private sector or
– by way of meeting IPHS norms/ Quality of care standards
established as per national guidelines, greater allocation of
untied funds as well as drugs and diagnostic services.
Untied funds for facilities:
• The current annual allocation under NRHM per SC (Rs. 20,000) and per
PHC (Rs. 1.75 lakhs) would remain the same.
• The annual untied fund amount per CHC: would be increased from the
current Rs. 2.5 lakhs to Rs. 5.0 lakhs, and for a DH it would be increased
from the current Rs. 5 lakhs to Rs. 10 lakhs
• Untied funds, funds for RKS and untied maintenance facility level funds
will be merged into a single untied grant to the facility.
• Funds admissible for different levels of facilities viz: SC, PHC, CHC,
SDH, would be pooled according to the category of facility, at the district
level and allocated to individual facilities based on utilization of funds,
case loads, range of services, keeping equity considerations in
• VHSNC: expenditures upto Rs 10,000 per VHSNC- but to flow
according to utilisation and needs, with an increase of ceiling by
10% per year. The total funds for VHSNC in a district will be
• Community Process interventions, including Grievance
– At the district and sub-district level upto 5% of the total
Community processes (VHSNCs, ASHA and grievance
redressal budgets taken together).
– At the state level 2% of entire costs of VHSNCs, ASHA
programme and Grievance redressal components taken
together could be to resource center(s) programme
– Support per ASHA upto Rs 15,000 per year, excluding
drugs and incentives. This is subject to a 5% increase per
– ASHA working in a population of 1000, (1000-2500 in
urban areas) to earn at least Rs. 3000 per month, (in
difficult areas where she serves populations of less than a
1000, additional incentives may be provided by states after
– Incentives at national and state levels may be appropriately
designed for a range of activities, based on the complexity
of tasks undertaken by the ASHAs.
• MMU: The existing cap of five per district can be relaxed
based on the area, difficult terrain, size of population, tribal
and LWE areas, which are underserved. Norms for capital and
operational expenditure will be suitable revised from time to
time based on Consumer Price Index (CPI) and range of
• BCC: Funds will be provided based on specific plans while
retaining the earlier norm of ceiling at Rs 10 per capita.
• Grant in aid to NGOs: Upto 5% of the NHM budget (of
resource envelope of state) to be used to support NGOs for a
range of activities
• M&E: 1% of the NHM funds – of which resource 20% may
be used at the national level, 30% at the State level and the rest
at district level and below.
• Technical Assistance: Upto 2% of the annual work plan -
includes establishment and consultant costs in State Health
System Research Centre and operational research and studies
and knowledge partnerships at the state and district levels
• Capacity Building: Upto 5% of the resource envelope for
costs of resource teams and institutions at all levels for
• Innovation fund and support for disaster management:
Upto 10% of the resource envelope would be used to fund
innovations at the state level. Disaster response related
interventions would be supported based on fund availability.
• Planning & Mapping: Indicative unit costs are as following:
– Rs.15 lac/city for planning/mapping of Metro cities
– Rs.10 lac/city for planning/mapping of cities with 1 million plus
– Rs.5 lac/city for planning/mapping of cities with 1- 10 lac
– Rs. 2 lac/town for planning/mapping of towns with 50,000- 1 lac
• Community Processes: Indicative unit costs are as following:
– MAS/community groups: Rs.5000 per year per MAS
– ASHA (urban): Approx. Rs.2000 pm per ASHA
Financial Norms (NUHM)
• Training & Capacity Building: Indicative unit costs are as
– Orientation of Urban Local Bodies (ULB): Rs.5 lakhs for
metros, Rs.3 lakhs for million+ cities, Rs.1 lakh for other cities
above 1 lakh and Rs.0.5 lakhs for smaller towns below 1 lakh
– Training of ANM/paramedical staff: Maximum Rs.5000 per
ANM (for entire training package)
– Training of Medical Officers: Maximum Rs.10,000 per MO (for
entire training package)
– Orientation of MAS: Orientation of MAS
– Selection & Training of ASHA: Maximum Rs.10,000 per ASHA
(for entire training package)
Financial Norms (NUHM)
• Strengthening of Health Services: Indicative unit costs are as following:
– Outreach services/camps/UHNDs: Maximum Rs.10,000 per
– Salary support for ANM/LHV: Maximum Rs.12,500 pm for ANM;
Maximum Rs.15,000 pm for LHV
– Mobility support for ANM/LHV: Rs.500/m
– Renovation/up-gradation of existing facility to UPHC: Rs.10 lakhs per
– Operating cost support for running UPHC (other than untied grants
and medicines & consumables): Rs.20 lakhs per year per UPHC
– Untied grants to UPHC: Rs.2.50 lakhs per year per UPHC
– Medicines & Consumables for UPHC: Rs.12.50 lakhs per year per
– Untied grants for UCHC: Rs.5 lakhs per year per hospital
Financial Norms (NUHM)
• DHAP is a guiding document appraised and approved at State level
for implementation, monitoring & evaluation of NRHM activities in
the district making decentralized programme management more
responsive to the health care needs of local community.
• District Health Mission with support from District Health Society
has been entrusted with the responsibility of steering formulation
and ensuring implementation of the plan
• Bottoms up approach of village heath plan>SC Health plan> PHC
Heath Action Plan> Block Health action plan>DHAP>PIP for
planning and budgeting.
• Untied funds, funds for RKS and untied maintenance facility level
funds will be merged into a single untied grant to the facility
Take Home Message
• Broad framework for preparation of district health action plans
• NUHM PIP guidelines 2014-17
• PIP overview 2014-17
• Textbook of community medicine - sunder lal