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 Achievements

National Rural Health

Mission

(By 2012)

MMR: 100/100,000 Live

Births

IMR: 30/1000 Live Births

TFR: 2.1

MMR : 212

(Ref: SRS 2008)

IMR: 47

(Ref: SRS 2010)

U5MR: 64

(Ref: SRS 2009)

Total Fertility Rate: 2.6

(Ref : SRS 2008)

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

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.

Uttar Pradesh 36%

Bihar 13%

Rajasthan 10%

Madhya Pradesh 9%

Assam 5%

West Bengal 4%

Orissa 4%

Jharkhand 4%

Karnataka 4%

Andhra Pradesh 4%

Maharashtra 4%

Gujarat 3%

Chhattisgarh 3%

Tamilnadu 2%

Haryana 2%

Punjab 1%

Uttarakhand 1%

Kerala 1%

6 73% of maternal mortality occurs in 5 large states.

INFANT AND NEONATAL MORTALITY RATE

Decline in NMR very slow – only by one point per year

Steady decline in IMR in recent years

Steady decline, but still a long way to go Estimated number of under 5 deaths in India: 1.7 million annually

Significant gap

Policy Options for Maternal and Child Health : Key decisions taken under NRHM

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expenses); User fees withdrawn for all MNH services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:

Improving availability of

outreach services–

immunization, antenatal

care, and contraceptive

access

• 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

Reaching the unreached

and underserved

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

1. Service Delivery

2. Health Workforce

Increasing Human Resources

Addition in workforce in the

NRHM period (2005-2012)

on a baseline of about

150,000 health workers

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)

Increasing availability of

health workforce

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

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

Setting up of Medical & Paramedical Institutions with an

emphasis on un-served and under-served areas

Strengthening of SIHFWs, RHFWTCs, ANMTCs & DTCs

Enhancing skills Comprehensive technical training in Maternal , new-born

and Child Health

Multiskilling of doctors undertaken to address gaps in

Specialist cadre (paediatricians, gynaecologists and

anaesthetists)

2. Health Workforce

Governance reforms

Key Decisions Output

Establishing

management

systems at all

levels

• Established 35 State Health Societies; over

600 District Health Societies with inter-

sectoral 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.

District health society

State health society

NRHM

3. Governance

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)

(Source: Expenditure Budget Vol. I GoI 2001-02 to 2010) and 2010-11is Revised Estimate and 2011-12 Budget Estimates

15

Rs. In Crores

Includes the expenditure on Health and Family Welfare, AYUSH and Health Research

2000

7000

12000

17000

22000

27000

320002

00

1-0

2

20

02

-03

20

03

-04

20

04

-05

20

05

-06

20

06

-07

20

07

-08

20

08

-09

20

09

-10

20

10

-11

(RE)

20

11

-12

(B

E)

Financing of Reproductive and Child Health programme

Key Decisions Output

Enhanced capacity to

utilize funds

• Audited RCH II expenditure increased 3.5 times in 3 years (2006-

07 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.

Greater accountability and

transparency

• 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

Decentralised and flexible

funding

• 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

• 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.

Health Insurance 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

4. Financing

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

5. Medical Products, Vaccines and Technology

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

6. Cross cutting policy decisions

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