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3 rd Common Review Mission UTTARAKHAND

3 rd Common Review Mission UTTARAKHAND. December 22, 2009. Team MEMBERS. Dr. Manisha Malhotra, MOHFW, GoI Dr. Anil Kumar, DGHS, MOHFW, GoI Ms. Shagun Mehrotra, European Commission Dr. Ravish Behal, RCH II TMSA Ms. Deepika Shrivastava, UNICEF India

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3 rd Common Review Mission UTTARAKHAND

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  1. 3rd Common Review MissionUTTARAKHAND December 22, 2009

  2. Team MEMBERS • Dr. Manisha Malhotra, MOHFW, GoI • Dr. Anil Kumar, DGHS, MOHFW, GoI • Ms. Shagun Mehrotra, European Commission • Dr. Ravish Behal, RCH II TMSA • Ms. Deepika Shrivastava, UNICEF India • Dr. Abhijit Das, Centre for Health & Social Justice

  3. Districts visited TehriGarhwal Almora

  4. The following table shows : State Health Infrastructure

  5. KEYINDICATORS

  6. Key Observations

  7. Infrastructure • NRHM contribution significant to infrastructure improvement • Inadequate infrastructure development plan • Facility planning / location – based more on land availability than on overall accessibility / need • Co location (e.g. PHC/SC and CHC/SC) & some clustering • State Allopathic Dispensaries not integrated into NRHM • Nomenclature of facilities not harmonised with GOI and IPHS • Availability of amenities: • power back up + ,cleanliness average, water shortages • Residential accommodation for providers by and large available at CHCs and PHCs – sometimes not occupied • Inadequate at District Hospitals and sub-centres • Temporary arrangements for attendants not available • Equipments: largely available, inadequately utilised • operating eye microscope, lift, inverter; lack of AMC arrangements • DHs and SDHs without functioning blood storage units/ blood banks • Mobility support for Block PHC MO I/C is inadequate - especially in hard to reach areas

  8. Human Resources • Overall shortage of skilled human resources and difficulties in retention in hard to reach areas • Overall supply capacity low (5 ANMTCs recently revived, only one govt. medical college – set up recently) • Shortage of Anaesthetists in particular • Remuneration package not attractive and lower than neighbouring states • Delays in state recruitment processes-Doctors, ANMs and LTs • Inadequate promotion and professional growth avenues • In-service training at limited number of institutions, that are overstretched • Lack of training opportunities for MOs in hard to reach areas • Lack of integration/ institutionalisation of contractual employees • Mismatch in deployment of available resources • Post training deployment not utilising newly acquired skills e.g. LSAS trained MO in PHC and in CHC/FRU without complement of Ob-Gyn or Paediatrician; no Ob-Gyn in DH; Ob-Gyn in SDH not providing EmOC

  9. Human Resources (contd..) • Positives /Steps taken: • New / renovated ANMTC, Medical college, and SIHFW coming up at D.Dun; tie up with MP for post-basic nursing education • Service providers, particularly MOs, and many ANMs possess reasonable knowledge and core skills ( despite lack of in-service training) • Skill-based training for MCH initiated.

  10. Service Utilisation • Increase in case loads due to NRHM, JSY and ASHA • OP, IP, immunisation , institutional delivery, reduction in DOTS defaulters • Community expectation for service delivery increased • EMRI 108 Services universally used and appreciated • However difficulties in transporting women to roadheads • Timely JSY payments useful • Enhanced communication for service delivery • Publicising of mobile phone numbers • Sub optimal utilisation of DH / SDH/ District Female Hospital • lower delivery load than some PHCs • Inadequate preparedness of facilities for EmOC/ other emergencies/ Newborn care • Blood storage/ bank availability, lack of key service providers, no residential staff

  11. Outreach Services • Village Health & Nutrition Days • Good session planning • organised in remote, underserved habitations • fixed day approach known to community • Good cross-sectoral linkages between frontline workers • Large thrust on immunisation; ANC and FP counselling, and B/F counselling to some extent • Nutrition counselling inadequate • Inadequate attention to growth monitoring and lack of knowledge on nutritional grading amongst ICDS functionaries • Inadequate monitoring of VHNDs • Mobile Medical Units • Systematically planned operation to provide maximum coverage of under-served areas (MMUs operated by Jain Video; HLFPPT) • Good OPD coverage (average attendance of 100 patients / day) • Availability of specialists and diagnostic facilities (X-ray, USG etc)

  12. Quality of Services • Privacy in OPD and labour rooms + • Signage display (citizens charter, drug availability, JSY provisions, other IEC) prominent • 48 hours stay post delivery not consistently ensured (client insistence) • JSY: Public disclosure of beneficiaries not uniformly seen; grievance redressal mechanisms yet to be set up • IMEP / BMWM weak; no adherence to GoI protocols

  13. Logistics & Supply Chain • Supply needs assessment and planning inadequate • Recent large supplies of Kit A, Kit B from GOI – MOs not informed of changes • Tedious procedures of procurement and distribution of supplies (60% done locally, 40% by state) • Cold chain was satisfactory in most facilities -however no generator, no temperature record in some (Barechina PHC ) • Nischay kits available in sub-centres and PHCs and being used.

  14. Decentralisation / Local action • Utilisation of untied funds at PHCs and sub-centres appropriate • RKS / ChikitsaPrabandhan Samitis just being set up at PHCs • Members are primarily Government functionaries • MOs orientation on use of RKS funds inadequate • AMGs for PHCs –utilisation not decentralised • at places being managed by CMOs • Contractual MOs not involved in planning for AMG and Untied Fund expenditures • District Health Action Plans available • Inadequate analysis of district level issues • Inadequate involvement of PRIs/ CSOs/ user groups / Block MOIC / ANM/ASHA • VHSCs • In the process of being formed • Inadequate orientation of PRIs • Community monitoring not yet initiated

  15. ASHA • ASHAs • Most visible face of NRHM • Completed all 5 training modules • High motivation and desire to be rooted in the health system. • ASHAs role and support well acknowledged by ANMs, ICDS AWWs, mothers communities • Adequate knowledge of MH services • Knowledge on CH / neonatal, nutrition counselling, and FP could be better • ASHA Resource Centre managed by distt MNGOs (Garhwal Community Development and Welfare Society (in Tehri) and INHERE (in Almora) • However, inadequate mentoring support to ASHAs at local levels- especially in hard to reach areas • Mechanisms in place for ensuring ASHA entitlements under JSY

  16. RCH II • Institutional deliveries have increased • Voucher Scheme in 5 districts through PPP • JSY payments timely with a few exceptions ; no inconsistencies noted between number of deliveries and beneficiaries • Counselling on PNC, B/F etc. being largely provided at facilities • Immunisation coverage has improved • FP-Sterilisation inadequate- 9.8 % of target till now • Neonatal care- inadequate attention • Safe abortion services not available across facilities • Referral transport available through EMRI 108 –with excellent tracking mechanism • difficulty in transporting pregnant women in hard to reach areas to roadhead- need for Palki transport • Unmet reproductive health needs of women –specific concerns related to load bearing • Social factors- gender discrimination, multiple burden on women, lack of rest after delivery, poor nutrition

  17. NDCPs • Slide examination for malaria inadequate – especially in terai area • No leprosy case under treatment in Almora; 3 cases in Tehri • 759 TB cases under treatment in Almora - but not seen as a priority • Integration of district level societies has not taken place

  18. Programme Management • Roles and job responsibilities of DPMU not uniformly clear • Attrition, possibly due to low remuneration • Advertisements on website of SHFWS for BPM not sufficient to tap local candidates • Qualification requirements for BPMs higher than the local available capacities • Induction and refresher training not being carried out systematically

  19. Financial Management • E-transfer of Funds at District, DH, SDH, CHC and PHC in practice; timely • Utilization Certificates are being sent only at the end of financial year • Release to districts: • RCH II – JSY, Sterilisation, rest lumpsum • Mission flexi pool – activity-wise • Immunisation – lumpsum • Individual NDCPs - lumpsum

  20. Key Issues

  21. KEY ISSUES • Excellent infrastructure underutilised due to • Poor geographical accessibility • Low catchment • Not providing full complement of services • Human Resource issues critical • Capacity Building (ANM, MO) will take time • Difficult area categorisation based on needs to be extended to sub-district/ block levels • Provider remuneration needs to be re-looked (lower than neighbouring states) • District institutions have inadequate load, hence cannot be used as sites for skill-based trainings • No clear plan for addressing neonatal mortality • Skill-based trainings, especially for MCH, to be fast tracked and linked to facility operationalisation plan • Performance based incentives for facilities to be re-looked. • Full complement of services not available at VHNDs

  22. Recommendations

  23. RECOMMENDATIONS • Overall orientation to NRHM and guidelines at all levels • Nomenclature and staffing of facilities as per GOI norms and IPHS • Infrastructure planning / location – needs to be linked to decentralised village microplanning/ tagging of hard to reach areas • Rationalise posting and transfers, improve incentives for hard to reach area within districts • Adapt recruitment procedures and requirements to tap and strengthen local capacity • Make 24x7 facilities fully operational and monitor them regularly • Improve range of Diagnostic facilities at all levels • Define opportunities for increasing contribution of SADs and AYUSH within NRHM eg. multi-skilling • Strengthen decentralized district planning processes, linking with other sectors –ICDS, TSC and expand planning to block and village level (bottom up) • Strengthen VHNDs with expanded activities e.g.GMP,Nutrition Counselling,referrals,salt testing • Greater orientation and sensitisation of PRIs and MOs for greater community ownership/communitisation

  24. Recommendations (Contd..) • Consider District Resource Centre for NRHM which will guide overall training and communication • ASHA mentoring support to be extended through cluster level networking/ facilitation • Joint training eg.NRHM-ICDS-SWAJAL for improved convergent action • Simplify the procurement procedures on the pattern of Tamilnadu Health System Corporation model. • Develop systems for AMC of Equipments • Provide greater mobility support to MOIC for improved support to peripheral action • Develop common bio-medical waste management facilities in urban areas like Haldwani with linkages to hilly areas • Give more focussed attention to addressing neonatal health at the facility and community levels • Arrange hands on training for utilisation of HMIS for review and planning • Regular feedback from 108 about functioning of emergency and referral services • IEC activities to address social issues affecting the health of women

  25. Policy Recommendations • Long term Human resource plan needed - • Capacity Building-Setting up of Medical Colleges, ANMTCs • Multiskilling and innovative approach to curative care • Telemedicine • Career progression and specialised training opportunity coupled with enhanced incentives for providers serving in hard-to-reach areas, with rotation policy • Way forward for ASHAs ? • Define progressive quality standards for different service delivery levels, with flexibility in approach for hard-to-reach areas

  26. THANK YOU

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