NRHM Review – A few key issues for consideration

1. NRHM Review – A few key issues for consideration Supervision, supply chain, support for building capacity, quality, monitoring outcomes

2. NRHM – Taking Stock • Very good progress in most of the States. • Large number of innovations. • Large scale addition of human resources. • Untied funds at all levels. • Institutions for community ownership • Management strengthening • Supply chain management • Skill development and capacity development • HMIS – Monitoring facilities, tracking pregnancy, child tracking, performance assessment. • Incentives in difficult, most difficult areas.

3. Key Challenges • Building capacity among community for supervision and support – VHSC, RKS. • Developing clear supervision structures for outcomes – Malaria, TB, MH, CH, Immunization, Family Planning. • No reason for a facility to be dirty – putting pressure to utilize untied resources – FAMILY FRIENDLY FACILITIES. • Making VHSCs vibrant. • Supply chain management • Monitoring effectively – HMIS, tracking. • Developing a public health cadre.

4. NRHM –Gains to health system • Human resources – 7 lakh ASHAs and one lakh health workers ( Specialists, Doctors, Nurses, ANMs, AYUSH doctors, Paramedics, etc.) under NRHM. • Physical infrastructure – 30% Sub Centre buildings, 20% PHCs, 75% CHCs, 90% District Hospitals being constructed/up graded. • Untied grants to all public institutions. • 1125 Mobile Medical Units across the country. • Over 10 States have Emergency medical system – others with more ambulances. • Doctors, drugs and diagnostics – improvement. • Public expenditure on health up.

5. NRHM – Institutional strengthening • VHSc, PRIs, RKSs, DHMs, SHMs, MSG. • Joint Bank Accounts for VHSC and Sub Centres. • Registered RogiKalyanSamitis at PHC and above – legal entity – insurance, etc. • Flexibility and adequacy of funding with accountability framework to ensure public action. • Decentralized planning and implementation • States, districts, blocks, villages deciding priority for public health action. • System for procurement and logistics – TNMSC. • Improving Human Resource Management.

6. NRHM – System strengthening • Financial Management – FMR • Programme Management – SPMU, DPMU • Data Management - HMIS • Development of Standards – IPHS • Capacity development for public health – public health management master’s (PHFI) and diploma (PHRN – IGNOU). • Family Medicine programme – CMC Vellore • Professional Development Courses – NIHFW, SIHFWs • Accountability system – Concurrent Evaluation, Community Monitoring, Performance Audit of CAG.

7. I – COMMUNITIZATION While Institutions for community ownership have been established, large scale development of capacity is needed for effective communitization of Public Health services Transparency and accountability built into institutional arrangements – need for full public disclosure of all programme interventions

8. II – MEDICAL EDUCATION A few District Hospitals in high focus States must have a road map to become Medical Colleges – reforms in MCI needed to facilitate such a process without compromising excellence New courses aimed exclusively at in-service public sector needs: One year Public Health Management Diploma through PHFI, 2 year Distance Family Medicine Programme through CMC, Vellore, more DNB in Family Medicine in District Hospitals etc. proposed Need for accelerating multi-skilling as a general policy but immediately for gynecologists and anesthetists and at looking at Follow outcomes of state experiments in three year programme of Rural Medical Assistants and Rural Health Practitioners in Chhattisgarh and Assam

9. III – NURSING EDUCATION Priority attention to improve and enhance in-take in all existing Government Nursing Institutions New Nursing Schools and Colleges in deficient States with partnerships in faculty from surplus States Partnerships with non-governmental sector for Nursing courses Reservation of seats for ASHAs and Aanganwadi workers based on local criteria in ANM/Nursing Schools

10. IV – PROCUREMENT AND LOGISTICS Effective and efficient public system of health care needs transparent, timely and quality procurement and logistic systems TNMSC – an exemplar Jan Aushadhiprogramme for promotion of generic drugs and for essential drug lists Need for corporations in States to manage infrastructure, drugs and equipment Need for a transparency act like in Tamilnadu.

11. V – HUMAN RESOURCE MANAGEMENT REFORMS New cadre rules that allow Specialists for Block Hospitals Incentives for difficult areas and performance linked incentives Continuing Medical and Nursing Education targeted at all cutting edge health functionaries Restructuring Directorates to lead more effectively towards delivery of quality services Move in direction suggested by Draft Task Force report on Human Resource Management shared at Puducherry workshop

12. VI – GOVERNANCE REFORMS Even greater thrust on transparency, accountability and full public disclosure Reforms in cadre management, transfer and posting policies, and in higher compensation for difficult areas Shift in focus from employment guarantee to service guarantee

13. Some key action points • Quality in JSY – need to rework demand side payments that ensure quality. • Thrust on nutrition and neonatal mortality. • Thrust on infectious diseases: TB, Malaria, Kala-azar - public health measures. • Making supervisory structures effective. • Making VHSCs and RKSs effective. • Expanding human resource potential. • Creating Public Health cadre. • Need for Public Health Act.

14. Addressing difficult area issues • Human resources – monetary and non-monetary incentives. • Reaching the unreached. • Safe home deliveries – delivery huts. • Home based care for neonates. • Stay facilities in health centres – for those coming from remote areas. • Infrastructure plan. • Norms for facilities. • Developing a local cadre of skilled, resident health workers.