Dr. Ajay Khera Deputy Commissioner Ministry of Health and Family Welfare,

Dr. Ajay Khera
Deputy Commissioner
Ministry of Health and Family
Welfare,
Government of India
February 17th , 2012
1
What has India achieved so far?
Goals
National Rural Health
Mission
(By 2012)
 MMR: 100/100,000 Live
Births
 IMR: 30/1000 Live Births
 TFR: 2.1
Achievements
 MMR : 212
(Ref: SRS 2008)
 IMR: 47
Millennium
Development Goal
(By 2015)
 MMR: Reduce by 3/4ths;
424 (1993) to
106/100,000 Live Births.
 IMR: Reduce by 2/3rds
80 (1990) to 27/1000
Live Births
(Ref: SRS 2010)
 U5MR: 64
(Ref: SRS 2009)
 Total Fertility Rate: 2.6
(Ref : SRS 2008)
 Under 5 MR: Reduce by
2/3rds; 118 (1990) to
42/1000 Live Births
3
MATERNAL MORTALITY RATIO
47
pt.s
42
pt.s
112
pt.s
MMR ACROSS STATES
Achievement of goals
varies across the states;
Progress needs to be
much faster across all
states if India is to
achieve the goal.
Maharashtra
4%
Andhra Pradesh
4%
Gujarat
3%
Chhattisgarh
3%
Uttar Pradesh
36%
Tamilnadu
2%
Karnataka
4%
Jharkhand
4%
Haryana
2%
Orissa
4%
Punjab
1%
Uttarakhand
1%
West Bengal
4%
Kerala
1%
Assam
5%
Bihar
13%
Madhya Pradesh
9%
Rajasthan
10%
73% of maternal mortality occurs in 5 large states.
6
INFANT AND NEONATAL MORTALITY RATE
Steady decline in IMR in recent years
Decline in NMR very slow – only by one point per year
Significant
gap
Steady decline, but still a long way to go
Estimated number of under 5 deaths in India: 1.7 million annually
Policy Options for Maternal and Child Health :
Key decisions taken under NRHM
1. Service Delivery
Improving access to services , universally, with continuum of care
Key Decisions
Output
Strengthening Primary
Health Care facilities for
Service Delivery
•
Basic Emergency Obstetric care available at 8330 PHCs that
function 24* 7
•
Essential Newborn Care at 9,800 delivery points
Demand side promotion
•
Janani Suraksha Yojana: Cash Transfer Scheme for women delivering
in public and private accredited institutions
•
Continues to extend coverage: Currently over 10 Million
beneficiaries per year
Free Referral Transport
•
JSSK: Cash-less, Supply side financed, Assured referral transport
system in 19 states
Service Guarantee
•
JSSK or Janani Shishu Suraksha Karyakram guarantees services for
pregnant women and new-borns (ensures Zero out of pocket
expenses); User fees withdrawn for all MNH services
Advanced Obstetric and
Newborn Care at referral
centers
•
2353 Referral Hospitals with CEmONC capacity
•
340 Newborn intensive care
1. Service Delivery
Improving access to services , universally, with continuum of care
Key Decisions
Output
Strengthening Community
processes:
•
855,168 ASHAs (Accredited Social Health Activist) facilitating
access to services, mobilizing communities and providing
community level care
•
4.96 lakh Village Health, Sanitation and Nutrition Committees in
place, with untied funds; provide a platform for convergence,
articulation of needs and gaps.
•
Rogi Kalyan Samitis- Promoting Public participation in facility
management

Mobile Medical Units functional in 461 districts , focus is on
improving efficiency (eg; GPRS tracking & monitoring)
Safe home deliveries in inaccessible areas through SBA trained
ANMs
Improving availability of
outreach services–
immunization, antenatal
care, and contraceptive
access
Reaching the unreached
and underserved

2. Health Workforce
Increasing Human Resources
Addition in workforce in the
NRHM period (2005-2012)
on a baseline of about
150,000 health workers
Increasing availability of
health workforce


8,630 Medical Officers
3,028 specialists


32,860 nurses
14,434 Para-medicals


66,784 ANMs (Community level)
8,55,168 ASHAs (Community level)

10,581 AYUSH doctors (indigenous system of medicine)

Filling up of sanctioned posts urgently ; sanctioning of new
posts as per IPHS requirements; and creating positions for
programme management / Administrative functions to free
doctors for clinical work
Measures for attracting and retaining skilled service providers
in rural and difficult areas
Developing a robust HR Management Information System in
progress in many states ; Rational Deployment of staff at
health facilities


2. Health Workforce
Increasing human resources, capacities and skills
Key Decisions
Expansion of Nursing and
Medical education: 300%
increase in nursing & 38%
increase in seats for medical
education

Enhancing skills



Setting up of Medical & Paramedical Institutions with an
emphasis on un-served and under-served areas
Strengthening of SIHFWs, RHFWTCs, ANMTCs & DTCs
Comprehensive technical training in Maternal , new-born
and Child Health
Multiskilling of doctors undertaken to address gaps in
Specialist cadre (paediatricians, gynaecologists and
anaesthetists)
3. Governance
Governance reforms
Key Decisions
Output
Establishing
management
systems at all
levels
•
•
•
•
Established 35 State Health Societies; over
600 District Health Societies with intersectoral participation and mandatory
representation for elected local bodies in
these societies.
Over 29,000 Rogi Kalyan Samiti/Hospital
Development Societies created. About 25% of
all funds goes as untied- grants to the facility.
Addition of 580 managers, 555 Accounts and
513 Data managers, epidemiologists in every
district and state.
Established nationwide information system,
electronic accounting process, multiple
accountability mechanisms.
NRHM
State health
society
District
health
society
4. Financing
Increasing GoI Health Budget
Increase of 21.5% per year during NRHM Phase (2004-06 to 2008-09) as
against 10.8% per year in Pre NRHM period (2001-02 to 2004-05)
Rs. In Crores
32000
27000
22000
17000
12000
7000
2011-12 (BE)
2010-11(RE)
2009-10
2008-09
2007-08
2006-07
2005-06
2004-05
2003-04
2002-03
2001-02
2000
(Source: Expenditure Budget Vol. I GoI 2001-02 to 2010) and 2010-11is Revised Estimate and
2011-12 Budget Estimates
Includes the expenditure on Health and Family Welfare, AYUSH and Health Research
15
4. Financing
Financing of Reproductive and Child Health programme
Key Decisions
Output
Enhanced capacity to
utilize funds
•
•
•
Greater accountability and
transparency
•
•
Decentralised and flexible
funding
•
Audited RCH II expenditure increased 3.5 times in 3 years (200607 to 2009-10)
Reported expenditure for 2010-11 is Rs. 3711 crores which is
108% of the release for the year (as against about 94% in
previous years)
Increasing focus on supporting peripheral institutions (RKS and
VHSNC) in reconciling their funds position.
Many States have adopted e-transfer of funds in conjunction with
the use of Tally ERP-9 software
Compliance with statutory audits has enabled increasing
transparency and accountability
Integration of all programs under NRHM & Financial
decentralization in the form of untied funds has enabled targeting
local problems related to shortage of consumables, repairs,
mobility support.
4. Financing
Financing of Reproductive and Child Health Programme
Key Decisions
Output
Prioritisation for
investment of
resources
•
•
Health Insurance
Identification of 264 HFD (with relatively poor RCH
indicators) for priority planning, mentoring support and
investment of RCH funds
Identification of delivery points; focus on plugging of gaps
for assured delivery of wide ranging RCH services in all
identified delivery points. State-wise list of delivery
points prepared.
RSBY or Rashtriya Swasthya Bima Yojana (under
Ministry of Labour & Employment) covering BPL
families ; 23.5 million families enrolled ; provides
annual cover of Rs. 30,000
5. Medical Products, Vaccines and Technology
Drugs and Medical Products
Key Decisions
Output
Improving Supply Chain
management
•
•
Central procurement agency (CPA) as a society approved
recently
Procurement Management Information System (ProMIS): being
expanded to all states for Supply Chain management
Ensuring provision of
•
quality drugs at affordable
prices
•
•
Essential drug lists, drug formularies and standard treatment
guidelines are being made available to states
Essential Drugs (Generic) to be provided at the facilities
Jan Aushadhi Programme launched as PPP initiative for
providing generics and surgical products at affordable prices,
24*7; 44 pharmacies or Jan Aushadhi Kendras already
functioning
Bringing Vaccine Security
National Vaccine Policy published in 2011
Vaccine supply covers > 27 million new born & 3 million
pregnant women each year; newer vaccines introduced
(pentavalent with HiB, Hepatitis B, DPT)
Cold Chain System strengthened for better vaccine storage all
levels; > 25,000 cold chain points established in the country
•
•
•
6. Cross cutting policy decisions
Cross cutting policy decisions
Key Decisions
Output
Private Public
Partnerships
•
Several states have initiated PPPs for addressing critical barriers
e.g. access, gaps in HR, referral transport, diagnostic and
ancillary services. In 2010-11, private accredited health
institutions accounted for 25% of institutional deliveries in both
public and private accredited facilities; the corresponding share
for sterilisation services is 16%.
Addressing information
Gaps
•
Improving Healthy Behaviour Program (IHBP) launched to build
national and state level BCC capacity.
Evidence based planning
•
Emphasising on use of HMIS data for planning and monitoring,;
capacities enhanced across the states up to district levels
(availability of computers, software, HR for data management)
Improving Quality of
services
•
QA committees constituted & notified at the state level in all
States
Quality Certification of facilities: currently both external
(ISO/NABH) and internal certification taking place
•
Way Forward
•
Move towards ‘Facility Based Monitoring’ and ‘Results
Based Financing’
•
Bring Service Guarantee in public health facilities:
Continuum Of Free Care during antenatal, natal and
post natal period
•
Make Quality Certification of facilities more efficient
•
Augment Human Resources for Health
– Facilitating availability of HR a per IPHS 2010 norms;
addressing shortfall in difficult and hard to reach areas;
clearly defined human resources policy in the states
•
Wide publicity of entitlements; put Grievance
Redressal Mechanisms in place
•
Provision of Comprehensive Maternal health and
Neonatal Care; Addressing Skewed Child Sex Ratio