Dr. Ajay Khera Deputy Commissioner Ministry of Health and Family Welfare, Government of India February 17 th, 2012 1
What has India achieved so far?
Goals Achievements National Rural Health Mission (By 2012) MMR: 100/100,000 Live Births IMR: 30/1000 Live Births TFR: 2.1 MMR : 212 (Ref: SRS 2008) Millennium Development Goal (By 2015) MMR: Reduce by 3/4ths; 424 (1993) to 106/100,000 Live Births. IMR: Reduce by 2/3rds 80 (1990) to 27/1000 Live Births Under 5 MR: Reduce by 2/3rds; 118 (1990) to 42/1000 Live Births IMR: 47 (Ref: SRS 2010) U5MR: 64 (Ref: SRS 2009) Total Fertility Rate: 2.6 (Ref : SRS 2008) 3
MATERNAL MORTALITY RATIO 47 pt.s 42 pt.s 112 pt.s
MMR ACROSS STATES Achievement of goals varies across the states; Progress needs to be much faster across all states if India is to achieve the goal.
Maharashtra 4% Andhra Pradesh 4% Gujarat 3% Uttar Pradesh 36% Chhattisgarh 3% Karnataka 4% Tamilnadu 2% Jharkhand 4% Orissa 4% Haryana 2% Punjab 1% West Bengal 4% Assam 5% Madhya Pradesh 9% Rajasthan 10% Bihar 13% 73% of maternal mortality occurs in 5 large states. Uttarakhand 1% Kerala 1% 6
INFANT AND NEONATAL MORTALITY RATE Steady decline in IMR in recent years Decline in NMR very slow only by one point per year
Significant gap Steady decline, but still a long way to go Estimated number of under 5 deaths in India: 1.7 million annually
Policy Options for Maternal and Child Health : Key decisions taken under NRHM
1. Service Delivery Improving access to services, universally, with continuum of care Key Decisions Output Strengthening Primary Health Care facilities for Service Delivery Basic Emergency Obstetric care available at 8330 PHCs that function 24* 7 Essential Newborn Care at 9,800 delivery points Demand side promotion Janani Suraksha Yojana: Cash Transfer Scheme for women delivering in public and private accredited institutions Continues to extend coverage: Currently over 10 Million beneficiaries per year Free Referral Transport JSSK: Cash-less, Supply side financed, Assured referral transport system in 19 states Service Guarantee JSSK or Janani Shishu Suraksha Karyakram guarantees services for pregnant women and new-borns (ensures Zero out of pocket expenses); User fees withdrawn for all MNH services Advanced Obstetric and Newborn Care at referral centers 2353 Referral Hospitals with CEmONC capacity 340 Newborn intensive care
1. Service Delivery Improving access to services, universally, with continuum of care Key Decisions Output Strengthening Community processes: Improving availability of outreach services immunization, antenatal care, and contraceptive access 855,168 ASHAs (Accredited Social Health Activist) facilitating access to services, mobilizing communities and providing community level care 4.96 lakh Village Health, Sanitation and Nutrition Committees in place, with untied funds; provide a platform for convergence, articulation of needs and gaps. Rogi Kalyan Samitis- Promoting Public participation in facility management Reaching the unreached and underserved Mobile Medical Units functional in 461 districts, focus is on improving efficiency (eg; GPRS tracking & monitoring) Safe home deliveries in inaccessible areas through SBA trained ANMs
2. Health Workforce Increasing Human Resources Addition in workforce in the NRHM period (2005-2012) on a baseline of about 150,000 health workers 8,630 Medical Officers 3,028 specialists 32,860 nurses 14,434 Para-medicals 66,784 ANMs (Community level) 8,55,168 ASHAs (Community level) 10,581 AYUSH doctors (indigenous system of medicine) Increasing availability of health workforce Filling up of sanctioned posts urgently ; sanctioning of new posts as per IPHS requirements; and creating positions for programme management / Administrative functions to free doctors for clinical work Measures for attracting and retaining skilled service providers in rural and difficult areas Developing a robust HR Management Information System in progress in many states ; Rational Deployment of staff at health facilities
2. Health Workforce Increasing human resources, capacities and skills Key Decisions Expansion of Nursing and Medical education: 300% increase in nursing & 38% increase in seats for medical education Setting up of Medical & Paramedical Institutions with an emphasis on un-served and under-served areas Strengthening of SIHFWs, RHFWTCs, ANMTCs & DTCs Enhancing skills Comprehensive technical training in Maternal, new-born and Child Health Multiskilling of doctors undertaken to address gaps in Specialist cadre (paediatricians, gynaecologists and anaesthetists)
3. Governance Governance reforms Key Decisions Output NRHM Establishing management systems at all levels Established 35 State Health Societies; over 600 District Health Societies with intersectoral participation and mandatory representation for elected local bodies in these societies. Over 29,000 Rogi Kalyan Samiti/Hospital Development Societies created. About 25% of all funds goes as untied- grants to the facility. Addition of 580 managers, 555 Accounts and 513 Data managers, epidemiologists in every district and state. Established nationwide information system, electronic accounting process, multiple accountability mechanisms. State health society District health society
2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11(RE) 2011-12 (BE) 4. Financing Increasing GoI Health Budget Increase of 21.5% per year during NRHM Phase (2004-06 to 2008-09) as against 10.8% per year in Pre NRHM period (2001-02 to 2004-05) 32000 27000 22000 17000 12000 7000 2000 Rs. In Crores (Source: Expenditure Budget Vol. I GoI 2001-02 to 2010) and 2010-11is Revised Estimate and 2011-12 Budget Estimates Includes the expenditure on Health and Family Welfare, AYUSH and Health Research 15
4. Financing Financing of Reproductive and Child Health programme Key Decisions Enhanced capacity to utilize funds Greater accountability and transparency Decentralised and flexible funding Output Audited RCH II expenditure increased 3.5 times in 3 years (2006-07 to 2009-10) Reported expenditure for 2010-11 is Rs. 3711 crores which is 108% of the release for the year (as against about 94% in previous years) Increasing focus on supporting peripheral institutions (RKS and VHSNC) in reconciling their funds position. Many States have adopted e-transfer of funds in conjunction with the use of Tally ERP-9 software Compliance with statutory audits has enabled increasing transparency and accountability Integration of all programs under NRHM & Financial decentralization in the form of untied funds has enabled targeting local problems related to shortage of consumables, repairs, mobility support.
4. Financing Financing of Reproductive and Child Health Programme Key Decisions Prioritisation for investment of resources Output Identification of 264 HFD (with relatively poor RCH indicators) for priority planning, mentoring support and investment of RCH funds Identification of delivery points; focus on plugging of gaps for assured delivery of wide ranging RCH services in all identified delivery points. State-wise list of delivery points prepared. Health Insurance RSBY or Rashtriya Swasthya Bima Yojana (under Ministry of Labour & Employment) covering BPL families ; 23.5 million families enrolled ; provides annual cover of Rs. 30,000
5. Medical Products, Vaccines and Technology Drugs and Medical Products Key Decisions Improving Supply Chain management Ensuring provision of quality drugs at affordable prices Output Central procurement agency (CPA) as a society approved recently Procurement Management Information System (ProMIS): being expanded to all states for Supply Chain management Essential drug lists, drug formularies and standard treatment guidelines are being made available to states Essential Drugs (Generic) to be provided at the facilities Jan Aushadhi Programme launched as PPP initiative for providing generics and surgical products at affordable prices, 24*7; 44 pharmacies or Jan Aushadhi Kendras already functioning Bringing Vaccine Security National Vaccine Policy published in 2011 Vaccine supply covers > 27 million new born & 3 million pregnant women each year; newer vaccines introduced (pentavalent with HiB, Hepatitis B, DPT) Cold Chain System strengthened for better vaccine storage all levels; > 25,000 cold chain points established in the country
6. Cross cutting policy decisions Cross cutting policy decisions Key Decisions Private Public Partnerships Addressing information Gaps Output Several states have initiated PPPs for addressing critical barriers e.g. access, gaps in HR, referral transport, diagnostic and ancillary services. In 2010-11, private accredited health institutions accounted for 25% of institutional deliveries in both public and private accredited facilities; the corresponding share for sterilisation services is 16%. Improving Healthy Behaviour Program (IHBP) launched to build national and state level BCC capacity. Evidence based planning Emphasising on use of HMIS data for planning and monitoring,; capacities enhanced across the states up to district levels (availability of computers, software, HR for data management) Improving Quality of services QA committees constituted & notified at the state level in all States Quality Certification of facilities: currently both external (ISO/NABH) and internal certification taking place
Way Forward Move towards Facility Based Monitoring and Results Based Financing Bring Service Guarantee in public health facilities: Continuum Of Free Care during antenatal, natal and post natal period Make Quality Certification of facilities more efficient Augment Human Resources for Health Facilitating availability of HR a per IPHS 2010 norms; addressing shortfall in difficult and hard to reach areas; clearly defined human resources policy in the states Wide publicity of entitlements; put Grievance Redressal Mechanisms in place Provision of Comprehensive Maternal health and Neonatal Care; Addressing Skewed Child Sex Ratio