1. WELCOME TO THE NATIONAL RURAL HEALTH MISSION..
Promoting equity and excellence for Health for All

2. NATIONAL HEALTH MISSION
REACHING AFFORDABLE, QUALITY HEALTH CARE TO THE POOREST HOUSEHOLDS IN THE REMOTEST REGIONS

3. THE PROBLEMS
IMR/MMR is high and not declining fast enough, especially in rural areas and among the poor.
High and prohibitive out of pocket expenditure makes access of poor people to health services difficult. Major contributor to poverty and destitution.
Population stabilization is ineffective especially in a number of EAG States/ CMP districts.
Public health system was on the decline- poor governance, manpower shortages, ineffective service delivery.

4. THE PROBLEM - II
Involvement of community/PRIs/ local government/ user groups in health programmes is weak.
Mapping of people’s health needs is not undertaken leading to people’s needs being different from what the system has to offer.
Convergence at Zila Parishad level is weak – implications for wider determinants of health.

5. THE PROBLEM - III
Large non governmental sector meets health needs of poor - at a price, often unethically, over prescription, syringe –saline syndrome.
Government programmes have very little to do with the non – governmental sector even though it is 4-5 times larger and can improve indicators/outcomes.

6. THE STRUCTURE
Health is a State subject with a large number of vertical CSS /Centre funded disease control programmes, to be delivered through PHC system
Family Welfare is a concurrent subject with large GoI financing
Primary health care is a PRI devolved area – Mandated role of local governments.

7. The Problem with the structure
Vertical programmes with little horizontal integration at District, State and National levels – Urgency of restructuring!
MoH&FW doing too much administrative function – little time for leadership to States
Lack of ownership in many States- too many schemes, too inflexible, not need based.
High degree of variation across states.

8. Key bottle-necks to change
Very large private sector, thriving on out-of-pocket expenditures. Poor unable to meet the high cost of health care. No regulatory mechanisms in place.
considerable expertise in public health- very poor application of such expertise- problem with both nature of expertise and nature of application.
Dependence on international technical resources
Unwillingness to look for structural change and governance reform to deliver better and in a more coordinated way. International donors active in governance reform – but central and state leadership weak.

9. Some Key Issues”
Under-funded public health system but unable to utilise funds.
No skilled persons in rural areas but overcrowding in urban areas.
Problems of motivation: cadre management of doctors/para medics unsatisfactory/ unable to deliver
Lack of infrastructure and under-utilisation of infrastructure
Decentralisation agreed upon but with great obstacles to implementation.
Major issues of governance

10. What can be done …within our times
States
IMR
TFR
Life Expectancy
Per capita expenditure
Under weight children
Kerala 12
1.8 73
132
27%
Tamil Nadu 31 64
120
37%
Bihar 67
4.4 59 57
54% UP 85
4.8 72
52%

11. CMP PRIORITIES
Raise public spending on health to 2-3% of GDP over the next five years.
A national scheme for health insurance for poor families.
Higher public investment for communicable diseases/ AIDS.
Village women to be given responsibility for all development schemes relating to drinking water, sanitation, primary education, primary health and nutrition.

12. CMP PRIORITIES-II
Replicate success of southern States in family planning.
Special attention to poorer sections in matters of health care.
Food and nutrition security.
Life saving drugs at reasonable prices.

13. Goals of the Mission Reduction in IMR and MMR.
Universal access to public health services such as women’s health, child health, water, sanitation and hygiene, immunization and nutrition.
Prevention and control of communicable and non-communicable diseases, including locally endemic diseases.
Access to integrated comprehensive primary health care.
Population stabilization, gender and demographic balance.
Revitalize local health traditions and mainstream AYUSH.
Promotion of healthy life styles.

14. To achieve these goals NRHM will:
Facilitate increased access and utilization of quality health services by all.
Forge a partnership between the Central, State and the local governments.
Set up a platform for involving the Panchayati Raj institutions and community in the management of primary health programmes and infrastructure.
Provide an opportunity for promoting equity and social justice.
Establish a mechanism to provide flexibility to the states and the community to promote local initiatives.
Develop a framework for promoting inter-sectoral convergence for promotive and preventive health care.

15. Expected Outcomes from the Mission
IMR reduced to 30 per live births by 2012.
Maternal Mortality reduced to 100/100,000 by 2012.
TFR reduced to 2.1 by 2012.
Reduction in mortality due to malaria, dengue and Kala-azar; Filaria elimination % cure rate under TB DOTs.
46 lakh cataract operations by 2012.
Upgrading CHCs to IPHS; Increase utilization of FRUs from 20% to 75%;
Engaging 2,50,000 ASHAs in 10 States.

16. Expected Outcomes at community level
Availability of trained community level worker at village level, with a drug kit for generic ailments.
Health Day at Anganwadi level on a fixed day/month for provision of immunization, ante/post natal check ups and services related to mother and child care, including nutrition.
Availability of generic drugs for common ailments at sub centre/hospital level.
Good hospital care through assured availability of doctors, drugs and quality services at PHC/CHC level.
Improved access to universal immunization.
Improved facilities for institutional deliveries.
Availability of assured health care at reduced financial risk through pilots of Community Health Insurance.
Provision of household toilets.
Improve outreach services through mobile medical unit at district level.

17. NRHM – 5 MAIN APPROACHES COMMUNITIZE/ DECENTRALIZE
Decentralized planning,
Hospital Management
Committees with PRIs at all levels
3. Untied grants to community/
PRI Bodies
4. Funds, functions to local
community organizations,
5.ASHA programme
6.Village Health &
Sanitation Com.
MONITOR,
PROGRESS AGAINST
STANDARDS
1. Setting IPHS Standards
2. Facility Surveys
3. Independent Monitoring
Committees at
Block, District & State
levels
FLEXIBLE FINANCING
1. Untied grants to institutions
2. NGO sector for Public
Health goals
3. NGOs as implementers
4. Risk Pooling – money
follows patient
5. More resources for
more reforms
IMPROVED
MANAGEMENT
THROUGH CAPACITY
1. Block & District Health
Office with management skills
2. NGOs in capacity building
3. NHSRC / SHSRC / DRG / BRG
4. Continuous skill development
support
INNOVATION IN
HUMAN RESOURCE
MANAGEMENT
1. More Nurses – local
Resident criteria
2. 24 X 7 emergencies by
Nurses at PHC. AYUSH
x 7 medical emergency
at CHC
4. Multi skilling

18. Health Financing
NOW
20% public expenditure (0.9% GDP), often inefficient and ineffective.
80% private expenditure, mostly out of pocket
15-20% MoHFW expenditure – rest by States
By 2012
40% public expenditure with improved accountability and efficiency ( 2-3% GDP)
Private expenditure by risk pooling/insurance – less duress and distress
40% GoI expenditure – rest by States

19. The Paradigm Shift:- 1 Decentralised planning: The directions
2006 – state PIPs
2007 –district PIPs and state PIPs
2008- block disaggregation in all dt PIPs and state PIPs.
2009 – all villages should be having village health plans
Need to create capacity.
Need to create quality and appraisal mechanisms
Need to address uneven development

20. Implications for Monitoring
Need to have state specific & district specific monitoring plans
Need to look at good qaulity appraisal mechanisms
Need to develop ways of reaching technical support to weak sections.
Need to define central common standards that all would have – irrespective of decentralisation – eg equity concerns

21. Implications for Financing
Need to define financial flexi pools for each state/ for each district.
Need to have norms for what various components can go to – without norms becoming entitlements. So we are more interested in proportions

22. Shift of Paradigm -2 Outputs and Outcome based – not input based:
Not how many buildings were built , how many training were conducted – but how it impacted on behavior change, service delivery, and on health status.

23. Implications for monitoring
Need to develop indicators for each strategy and scheme
Need to understand the relationship of a set of inputs ( which is a scheme ) to both outputs and outcomes– and to impact!!
Need to be able to measure baselines.
Need to be able to have a monitoring strategy that can periodically measure these indicators with high degree of reliability.
Need to be able to deal with state/district specific indicators which vary between states/districts.
Need to have a common core set of outputs and outcomes across the states/districts.

24. Implications for financing
Release of installments and next year grants should be based on outputs and outcomes.
Financial envelopes should reward good performance.( performance related funding)
Financial envelopes should provide more funds to weaker areas – but not for weaker performance!! Systems should be able to discriminate between the two.
Gaps between inputs and outputs should trigger re-examination of strategy; strengthening governance mechanisms.
This requires a high quality monitoring system.

25. Shift of Paradigm -3 Pro-Poor Focus: Equitable systems
Equity across states/districts
Equity by caste and ethnicity.
Equity be gender
Building it into plans
Building it into monitoring systems
Building it into financing systems

26. Shift of Paradigm -4 Quality of Care and the IPHS norms
Each facility is defined by the set of services it delivers.
A set of inputs that match an approximate estimated patient load is also specified.
How does one monitor quality of care?
How does one finance for improved quality of care?- when to use untied funds and when to use vertical schemes.

27. Shift of Paradigm- 5
Community Participation: Bringing the public back into public health:
At the hamlet level : ASHA, village committees, SHGs and panchayats.
At the facility level: hospital management committees
At the management level – health societies
How are these monitored and how do they contribute to monitoring?
How does financing change with respect to these structures

28. Shift of Paradigm -6 Flexible Funding-
HSCs, Village and sanitation committees, Hospital management committees of PHCs and CHCs are all provided untied funds.
Do we know what they spend it on?
Do we need to know this?
What is the best way to make use of it – to reach quality norms and facilitate public participation. Are the systems and capacities in place
How is financing distributed between institutions?
How is accounting done.

29. Shift of Paradigm -7 Improved Governance – Governance reform
Workforce Management
Procurement processes.
Decision making processes
Institutional design
Accountability framework
Central to many problems.
Development partners insist on governance reforms with states- but is central govt able to so insist?
How states can use these mechanisms to improve governance?
How does one monitor good governance? How does one reward good governance and limit poor governance and leakages? How does this relate to problems of UCs and poor absorption of fund flows.

30. Shift of Paradigm -8 Convergence
Water and sanitation
Nutrition
Education
How does monitor development in these sectors and their contribution to outcomes?
How to build indicators that indicate synergy?
How to deal with financing similar issues and cross financing- in training and other programmes

31. Necessary component
Health Human Resources Planning & management under the NRHM
Implications for monitoring and financing…..

32. Thank You.