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Evaluation of NRHM in Karnataka

Evaluation of NRHM in Karnataka. Presented to Principal Secretary, Department of Planning Programme Monitoring and Statistics Government of Karnataka. Agenda. Introduction to the project Background and Literature Study Methodology of the evaluation Phase 1 Phase 2

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Evaluation of NRHM in Karnataka

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  1. Evaluation of NRHM in Karnataka Presented to Principal Secretary, Department of Planning Programme Monitoring and Statistics Government of Karnataka

  2. Agenda • Introduction to the project • Background and Literature Study • Methodology of the evaluation • Phase 1 • Phase 2 • Secondary data analysis • Regional Imbalances • Summary of Phase 1 • Summary of Phase 2 • Recommendations

  3. Introduction • The evaluation study was taken up based on • Proceedings of the meeting held on 9th Sept 2011, chaired by the Chief Secretary, GOK • Govt. Order No: PD 30 EVN 2011, Bangalore, dated 16th November 2011 • To understand the planning and execution processes of NRHM in Karnataka • To understand the efficacy of allotment and flow of funds keeping the taluk as fundamental unit • To make policy suggestions for effective planning, allocation and utilization of funds for achieving goals of NRHM • Presented initial project update on 28th Jan 2012 to M D NRHM, SHRC • Presented phase 1 updates on 14th Sept. 2012 to Princ. Sec. Health. • Presented the final project results to MD, NRHM on 28-01-2013 3

  4. Terms of Reference • Phase I: NRHM Funds Allocation Structure and Design, current funding and utilization, implementation, and its impact on Karnataka’s Health Indicators • Phase 2: Field validation, stakeholder appraisal of NRHM’s planning processes at the local and regional level • Focus of the study • NRHM Fund Allocation, Structure and Design • NRHM’s Current Funding Allocation, its utilization, implementation, and its impact on Karnataka’s Health Indicators

  5. Phase I* • Study of existing planning and implementation processes • For identifying focus areas and prioritizing fund allocations • Study of current progress at the taluk level, • Health indicators, fund allocation and expenditure, status of physical infrastructure, human resources • What correlates with taluk health indicators? • Overall development status of the taluk • Funding allocated to that taluk • Physical infrastructure • Human resources • Community involvement • Certain combination of the above What is the optimum combination of inputs needed for improvement in health indicators at the taluka level? • Presented phase 1 updates on 14th Sept. 2012 to Princ. Sec. Health. 5

  6. Phase II • Understanding • Local NRHM related processes • NRHM’s planning, fund allocation and expenditures from the local perspective • Levels of community engagement, monitoring and ownership of public health systems • Validation and analysis of regional disparities. • Identification of local challenges and gaps. • Possible policy advocacy options obtained during this study 6

  7. Phase 1 Objectives • Identify regional (inter-district/intra-district) disparities in physical/human resource distribution • Assess relationship between fund allocations, expenditure on physical and human resources, development status and current health indicators • Develop a framework for identifying and mitigating regional/local disparities • Develop a comprehensive picture of funds flow and expenditure • Develop financial and/or health indicators, with standard and defined understanding, for allocating funds and to track efficiency and effectiveness of NRHM** • Research and analyze the gaps in planning, fund allocation and expenditure

  8. Phase 2 Objectives • Identify possible gaps between existing planning processes, expenditure patterns and local health issue • Elicit viable policy advocacy options to address such gaps • Appraise community representatives about the findings of the study including regional/local disparities in health status, physical infrastructure, human resources and local development status • Understand actual NRHM related processes of bottom up planning, with local public health officials and community • Understand community engagement levels in health institutions • Understand local fund allocation and expenditure processes

  9. Background and Literature Study

  10. Literature Review Outputs • Review of health policies • National Health Policy 2002 • State Health Policy 2004 • Report of the NCMH 2005 • Understanding NRHM • Review of evaluations and critiques of NRHM • Analysis of PIPs and DHAPs • Our impressions • Agenda

  11. Review of health policies National Health Policy 2002, Karnataka State Integrated Health Policy 2004, Report of NCMH 2005 • Documents the condition of the public health sector of the country • Recognize challenges in like • low quality of health indicators (especially RCH), widespread disparities (regional, rural-urban, gender, social groups) • low levels of public investment in health, • lack of accountability of the public health system and • under-utilization of public health infrastructure and services

  12. Health Policies • Suggest road-map and strategies • increase in public investment, the active role of centre • the involvement of PRIs in all stages • the emphasis on primary health care and particularly PHCs and SCs • the importance of women’s health • inter-sectoral approach (nutrition, sanitation, water supply) • Importance of planning and monitoring • Reduction in regional disparities • HR reforms in the health sector • Public health cadre • Involvement of communities SHP is majorly based on the Task Force on Health and Family Welfare Report 2001

  13. Evaluations of NRHM • NRHM - Meeting People's Health Needs in Partnership with States - The Journey So Far - 2005 – 2010 • Increase in spending on health has not reached intended targets*. (annual increase in NRHM overlay ~ 20% , annual increase in expenditure ~ 25%) • Planning efficiency, monitoring of expenditure to be improved • Mismatch between pace of increase in demand and availability of infrastructure • Problems of HR • Decentralization is slow, needs to be fostered. • Common Review Missions (Second and Fifth Rounds) • Karnataka is better off in terms of health finances (since multiple sources of funds exist). • Infrastructure is impressive (more than required according to IPHS). However, quality of works needs attention. • Shortage of HR • Frameworks, processes in place, but need to be strengthened. • Decentralization has created some friction. • Funds utilized, but not transformed into higher utilization rates. * Figures presented are at the national level.

  14. Evaluations of NRHM • Report of the Working Group on NRHM for the Twelfth Five Year Plan (2012 – 2017) • Centre’s outlay on health has increased substantially. Together with this, state expenditure has also increased. • Karnataka lags significantly behind in IMR and MMR when compared to other southern states. May not achieve the targets with the current pace. • The largest share of NRHM funding has gone into infrastructure strengthening (31%) followed by RCH activities (28%) and disease control programmes (14%) • Funds released on ‘per facility normative basis’ and not responsive to utilization patterns leading to scarcity in some facilities and stagnant funds in others.

  15. Evaluations of NRHM • Performance audit of NRHM (CAG, 2008) • Funds released to states on share of population, rather than on equity/need. • Guidelines not being followed in expenditure • Poor accounts and record keeping (also field experience) • Concerns of under-utilization of funds (James et al, 2009) (Gayithri et al, 2011) • Inadequate understanding of NRHM • Confusion over spending of Untied Funds • Mismatch between releases and expenditure

  16. Evaluations of NRHM • Regional Disparities (Gayithri et al, 2011) • Allocation to districts based on population • Urban/rural/geographical/community/gender disparities (documented in many official documents) • Karnataka lags behind other southern states in terms of MMR (178) (SRS, 2009) • Kerala and TN have reached 100 • Estimated MMR of Karnataka in 2012: 130 • Health gains not in line with expenditure on infrastructure and activities

  17. NRHM – Field experiences • NRHM has played a major role in • improving infrastructure • increasing the reach of health services in rural areas • increasing institutional deliveries • reducing mortality rates • improving the overall general health of pregnant women and new mothers

  18. NRHM – Field experiences • Acute shortage of human resources • Issues in disbursal of funds in schemes like PA and JSY • Additional responsibilities: More time spent on documentation and logistics, reduced field time for field workers and MOs • Lack of proper documentation of fund position • Many PHCs, (some lack infrastructure, some are under-utilized), need more PHCs in some areas • Non-availability of drugs, extra charges for drugs • Mismatch in the planned and actual needs of the PHCs • Not many PHCs (and 24 X 7s) handle deliveries • True participation of VHSC and ARS in monitoring and management has a long way to go.

  19. Major Project outputs • Terms of Reference • Policies and evaluation outcomes • Map of fund flows • Analysis of fund flows • Regional imbalances • Correlation analysis • Local NRHM related processes and issues • Community perspectives • Local challenges and gaps

  20. Fund Flow in NRHM • Funds are released from the Centre through two routes : • Treasury and State Health Society • Funds released under following components through the society route • RCH Flexipool (RCH, Family Planning, JSY, PA, HR) • Mission Flexipool (Infrastructure, maintenance grants, untied funds, innovations, HR) • Routine Immunization • National Disease Control Programmes

  21. GoI NRHM Managed by Financial Management Group (FMG) State Govt State Govt. Share (15%) Managed by FMG and State Health Mission (SHM) State Level Expenses State Health Society Managed by FMG and District Health Mission (DHM) District Level Expenses District Health Society Block, CHC, PHC, SC Regular/United/Maintenance Grants

  22. A. RCH B. NRHM C. RI D. NDCP NRHM RCH and Mission Flexipool constitute the largest share and as such expected to have the largest impact SHM & SHS DHM & DHS NRHM NRHM RI Malaria TB Leprosy Blindness RCH

  23. Observations on PIPs • Do not seem to indicate district specific needs and innovations • May not cover actual action/implementation fully • New hospitals constructed , mentioned in next year’s PIP, not matching with PIP of previous years (Infrastructure Strengthening 2008-09, 2009-10 PIPs) • Only in a couple of years, do we see plans integrated from other projects like KHSDRP • Too ambitious in health outcomes Karnataka State PIP, 2009 – 10, pp: 13

  24. Analysis of DHAPs • DHAP is the corner stone of NRHM • considerable time and effort required to build decentralized planning capacities. • However, planning is not new, and in parallel, other planning activities are also going on. • Issues • A lot of data is collected and analysis of this data would give critical district specific information • Non-integration of different activities at the district level (w.r.t health itself as well as related sectors) • Needs and requirements mentioned in different sections of the DHAP are not integrated into the work plan section

  25. Analysis of Sample DHAPs • Issues (Continued) • A lot of material is repeated and taken verbatim from other sources. Most of this does not add any new value. • There is no follow up on DHAP of previous year. • The DHAPs do not mention the analysis of readily available district data through HMIS • The work plans do not explicitly mention prioritization of issues • No discussion on issues related to drug procurement and disbursal (although it’s a recurring practical issue) • The FMR reduces DHAPs to a costing framework • Innovations are basically state-level innovations, rather than those borne out of district needs.

  26. Our Impressions (based on literature review, analysis of PIPs and field experience) • Policies, mission documents, evaluations have clearly and comprehensively pointed out issues of concern. In actual planning and implementation, these concerns are not addressed. • Schemes are designed by top bureaucrats, activists and CBOs. Implementers of missions and schemes may not have internalized their objectives. Patterns of implementation haven’t change much at the ground level. • No valid benchmarks set in planning against which implementation activities can be evaluated. • Some indicators may not be sufficient to draw inferences (indicators on communitization) • Complex set of rules, guidelines and procedures (confusing both MOs as well as community) • Inefficiency and transaction costs continue to be significantly high • Agenda

  27. NRHM Funds Analysis • Methodology of analysis • Data sources • State level trends in • allocation and expenditure • status of health infrastructure • District trends • Correlational analysis • Regional imbalances

  28. Exploratory analysis Methodology of funds analysis Customized expenditure heads • HR • Infrastructure and Maintenance • RCH Prog. Activities • NRHM Prog Activities • RI Prog Activities • Drugs • IEC and Training • Administration NRHM Heads of Accounts, 3 major heads (from Statement of Expenditure) • RCH Flexipool • NRHM Flexipool • RI About 300 line items (FMR) Remapped Correlational analysis Selected indicators from HMIS

  29. Methodology of funds analysis • Exploratory analysis • Descriptive analysis of trends in financial and health indicators • Helps to identify un-natural and unexpected trends • Correlation analysis • Measures whether there is similarity in the trends of two or more variables. • Helps to identify whether the program expenditure is consistent with prior goals and objectives

  30. Health and Finance Data Sources • NRHM HMIS • Various publications on the NRHM’s GOI and GOK websites • Progress of Programme publications • Dynamic reports from HMIS • District Level Household Survey 3 • Rural Health Statistics • PIPs, ROPs and DHAPs of various years • District Statement of Expenditures – 2010-11 (FMR) (taluk-wise details not available) • SHS audit reports • Human Development Indices • Agenda

  31. Limitations in data • Facility based reports, gaps in HMIS. • Taluk level financial data not available during the time of analysis. • Changes in methodology • Ratios and comparative trends used for trend analysis • Correlational analysis done using representative holistic variables. • Use various sources of for data triangulation • Agenda

  32. Differences and limitations in data • IMR and MMR (HMIS data) • IMR in Karnataka - 38 (SRS Bulletin, Dec 2011) • MMR in Karnataka – 178 (SRS, 2009) • Agenda IMR: ratio of the number of deaths of babies under one year of age per 1,000 live births MMR: ratio of the number of maternal deaths per 100,000 live births

  33. Analysis of NRHM in Karnataka • State government expenditure on health and family welfare since 2007 has increased annually by 19%. • GOI allocation and release under NRHM has shown an increased annually by 22% and 25% respectively. • State’s NRHM expenditure has increased annually by around 40% Karnataka Budget documents NRHM – Statewise Progress as on 31-03-2012, NRHM Facility Centre, MOH&FW, GOI

  34. Analysis of NRHM in Karnataka • NRHM Flexipool is the major component, followed by RCH flexipool and infrastructure and maintenance grants (channeled through the revenue route) • Immunization funds form around 1%-2% of the total funds Approved ROPs (2007 – 2011)

  35. Analysis of NRHM in Karnataka Releases and expenditure of the State Health Society from 2005-09 NRHM – Statewise Progress as on 31-03-2012, NRHM Facility Centre, MOH&FW, GOI 2010 and 2011 expenditure figures - provisional

  36. District level trends in expenditure • Fund utilization levels at the district level has largely improved, (visible due to increasing absorption rates of NRHM flexipool funds. • Major allocation of funds is at the district level. • Overall funding pattern for districts relate to population (rather than rural population and health indicators) • Availability and timing of funds is not an issue at the district level. (Timing of fund releases within districts was problematic in previous years, based on findings in phase 2) • Funds released is usually higher than fund allotment • Districts with better health indicators seem to be spending more on infrastructure and maintenance (in their basket of allotment)

  37. NRHM Statement of expenditures (2005-10)

  38. Analysis of funds given to districts Health Ranks: Based on tables in situation analysis in State PIP – 2009-10 Population statistics: Census 2011 Funds received by districts: Yearly audit reports

  39. Districts with better health indicators seem to spend more available funds on infrastructure and maintenance

  40. Regional Imbalances • Regional imbalances recorded and presented in great detail in numerous documents and reports • State health policy • HPCRRI report (Dr Nanjundappa Report) • Individual PIPs • However, fund allocations in PIPs and DHAPs are driven by existing facilities* • * Other than RCH

  41. Mapping of PHCs in Karnataka Regional imbalances

  42. Regional Imbalances • Districts with more than 50% of PHCs as 24 x 7s • Chamarajanagar • Tumkur • Kolar • Gulbarga • Bidar • Bijapur • Koppal • Dharwad • Bagalkot Rural Health Statistics 2011

  43. Regional Imbalances* • * Places like Mandya, Mysore, Shimoga, Uttara Kannada have gained more • Agenda

  44. Correlation analysis - 1 • Relationship between expenditures, existing infrastructure and Health Indicators • district-wise expenditure under major heads: RCH NRHM and RI, for all years between 2005 – 2011 • existing health infrastructure (2011) • district populations in 2011 (and population growth rates) • Composite health indicator (devised by National Commission on Population, GOI, 2001, used in 2008-09 state PIP to demonstrate regional imbalances) – serves as a guideline for regional prioritization

  45. Correlation analysis - 1 • RCH expenditure is higher in regions with where health indicators are poor. • NRHM flexipool, Routine immunization and total funds in NRHM have not targeted the imbalance in health indicators. • Over-all expenditure is strongly and positively correlated with existing infrastructure. • Expenditure is strongly and positively correlated with district populations. • Existing infrastructure does not have significant correlation with population (and is corroborated with the imbalance analysis) • Infrastructure does not have significant correlation with health indicators (however, there is a general –ve relationship) • SCs, PHCs, CHCs, Sub-divisional hospitals are also highly positively correlated with each other

  46. Correlation analysis – 2 • The composite health indicator is positively correlated with HDI and per capita Income,. • RCH expenditures are negatively correlated with the composite health indicator, indicating better targeting of RCH funds. • Population covered by PHCs negatively correlated with the composite health indicator • districts where PHCs cover larger populations correspond to districts with lower health status (for example, Raichur) • NRHM expenditures are not significantly correlated to the composite health indicator (ideally, significant negative correlation is expected). • NRHM expenditures are not correlated with HDI and per capita income, • no significant trend of NRHM expenditures targeted towards districts with low per capita income or districts with lower HDIs. • Agenda

  47. Summary of findings of phase 1 • In the expenditure under NRHM in 2011, NRHM flexipool fund is the major component (about 44%), followed by RCH flexipool (27%) and infrastructure and maintenance grants (channeled through the treasury route (22%), and Immunization funds form only 1%-2% of the total funds. • NRHM flexipool fund distributed to districts is mostly facility based • The district allotment and expenditures strongly display facility based (rather than need based) funding patterns • Over-all expenditure under NRHM is strongly and positively correlated with existing infrastructure • Karnataka has not only utilized the full release from the Centre, but has also been able to utilize unspent amounts from previous years. • a matter of concern, especially because of the critical loopholes in planning and PIP preparation related processes

  48. Summary of findings of phase 1 • No clear trends of prioritized planning or expenditures to districts identified as vulnerable • Other than RCH expenditures (which are mainly demand based, and are principally dependent on the work of ASHA and ANMs), funds under NRHM flexipool and Routine immunization have not targeted the regional imbalance in health indicators • Continuation of the regional imbalances in health infrastructure and expenditures, even during the period of the implementation of NRHM in Karnataka • Agenda

  49. Summary of findings - Phase 1 Expected outcomes • A map of the funds flow • Identify the basis of fund flow mechanism • Track the state’s accomplishments vs. the state’s plans on a taluk level** • Identification of regional/local disparities • Measure the impact of existing infrastructure on health indicators • Assess the relation between funding and development status

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