Decentralisation Initiatives in Gujarat Health Sector Reforms Department of Health & FW

1. Decentralisation Initiatives in Gujarat Health Sector Reforms Department of Health & FW Government of Gujarat

2. Gujarat – A Profile The Planning Commission has set a target growth rate of 10% p.a. for Gujarat

3. Background • The Sector Investment Programme (SIP) started in Gujarat in January 2000, initially in two districts, Narmada and Rajkot • Following the earthquake in January 2001, 9 affected districts were also taken up to implement Reforms with Reconstruction • In January 2005 the remaining 14 districts were also covered under the SIP, making a total of 25 districts

4. Institutional mechanisms • The State Health Sector Reform Cell constituted in 1999 for the EC supported SIP • Standing Committee On Voluntary Action was created in early 2000 to expedite the disbursement of funds • The Reconstruction Sub Committee constituted in 2002 for post earthquake activities

5. Following the earthquake the State Programme Implementation Unit established to manage and administer the Repairs and Reconstruction of health facilities. • DPIUs were established to monitor and supervise the Repair and Reconstruction works at local level. • District Agencies at the district level to manage the reform component. They prepared their own District Action Plans in consultation with the community and the health functionaries to meet the local needs. • Flexibility in re-allocation of funds at the State and the District level according to the need and priority.

7. Government Policy Resolutions Delegation of Powers to Medical Officers PHCs, District Societies and Additional Director (Family Welfare) Delegation of financial and administrative powers to Medical Colleges, District Hospitals, Community Health Centres (CHCs) and PHCs Establishment of Block Health Offices (BHOs) Formation of Rogi Kalyan samities

8. Decentralisational processes in repair and reconstruction Earlier Total dependence on R&B

9. Major stakeholders involved and their role Now

10. Monitoring and Evaluation • Monthly Physical and Financial Progress Report (SOE) • Supervisory visits by state and district program managers • Review in District RCH society meetings and review in state and district level meetings

11. Issues • Lack of trust and fear - Funds could not be utilized in a few districts where District RCH societies did not release fund to MO • Fund flow to MOs delayed due to lack of Bank Account but now streamlined • Proper orientation to stake holders on purpose, process and output required • Delegation of powers only for donor agency fund, now being institutionalised

12. Work carried out by PIU (RSRR)

13. Progress Report NC -1

14. POST EARTHQUAKE REDEVELOPMENT PROGRAMMENEW CONSTRUCTION (Pipeline)

15. Chiranjivi

16. OBJECTIVES- Vision 2010, Population Policy & RCH II • Reduce MMR from 389 (in 1998) to 100 per 100,000 live births by 2010 • Reduce IMR from 60 to 30 by 2010 • Stabilize population by reducing TFR from 3.0 to 2.1 by 2010

17. Maternal Mortality: UK 1840–1960 Improvements in nutrition, sanitation Antibiotics, banked blood, surgical improvements Antenatal care Maine 1999.

18. Maternal Mortality ReductionSri Lanka 1940–1985 85% births attended by trained personnel

19. Three Delays Responsible for Maternal Deaths • Delay in deciding to seek care (Individual & family) • Lack of understanding of complications • Gender issues, Low status of women • Socio-cultural barriers to seeking care • Poor economic condition of the family • Delay in reaching care ( Community & System) • Lack or underutilization of transport funds • Non availability of referral transportation in remote places • Lack of communication network • Delay in receiving care (System) • Poor facilities, personnel and Supplies • Poorly trained personnel with indifferent attitude

20. Service Charges for participating Gynecs

21. Chiranjivi preliminary results

22. HRD Reforms • Grading of PHCs, CHCs and special training for poorly performing districts – manual for MOs – web site • Three month PDP for district and block level officers • “Karma yogi” motivational training program to change the attitude of government employees- conceptualized by Hon. Chief Minister • PG seats reserved for admissionsto doctors serving in rural areas - regular deputation for DPH programmes • Computerised data base for doctors • Filling up of vacant posts of MPHW by SI - three month Bridge course for sanitary inspectors

23. Innovations • Web based Integrated Disease Surveillance Programme • Improved MIS through computer applications- RCH software; • Transparency - information sharing through web site • CRS • GIS application – spatial distribution of health fcailities - Village wise data for malaria, and RCH • Urban health • NGOs

24. Innovations 2 • Decentralised recruitment of Medical Officers Powers of ad-hoc appointment delegated to RDDs • Chiranjivi • Rogi kalyan Samiti • Computerisation of hospitals • Telemedicine • MCCD

25. 1 Measles Banaskantha Kachchh Mahesana Patan 2 Measles, 4 Diphtheria Ahmedabad Surendranagar 1 Measles Rajkot Jamnagar 1 Measles 2 Diptheria 5 Measles Integrated Disease Surveillance

26. Next phase of reforms • Strategic planning cell • Functional management • Computerised financial management, budgeting, and auditing • Monitoring and evaluation functions • HRD systems • Extensive use of IT • Decentralised management through RDDs • Outsourcing CHCs and DHs • Revamped CMSO • Communitisation - effectiveVillage health societies • Ombudsman

27. Further Information • PROD reference number 2: Medical Officers authorised to arrange maintenance and repairs on Primary Health Centres, Gujarat. • PROD reference number 31 Establishment of District Health Agencies to manage health services, Various States. • www.prod-india.com

28. Government of Gujarat and European Union a fruitful partnership THANK YOU January 2006

29. Trends in leading causes of deaths

32. National RNTCP Status – 2Q04/2Q05 Cure Rate Case Detection Rate

33. School health programme • School check up for 10 million children annually • 1.6 million students treated on site; 75,000 students referred for tertiary care; more than 70,000 children given spectacles • More than 5000 children provided super specialist heart, kidney and cancer care at Government cost