National Health Policy and HMISNational Health Policy and HMIS

Dr.Kishore MurthyDr.Kishore Murthy

DirectorDirector

Institute for Health Management Research Institute for Health Management Research BangaloreBangalore

Health Policies and Health Policies and HMISHMIS

A Comprehensive, Integrated HMIS, A Comprehensive, Integrated HMIS, spanning all levels of a health service is a spanning all levels of a health service is a KEY component of a modern health system, KEY component of a modern health system, integrated to the effective and efficient integrated to the effective and efficient management of coordination of resources.management of coordination of resources.Common thread is for quality information Common thread is for quality information to drive and support processes in the to drive and support processes in the management of resourcesmanagement of resources..

National Health Policy: IndiaNational Health Policy: IndiaReview – National Health Policy:Review – National Health Policy:

First Evolution: 1983. Revised: 2002.First Evolution: 1983. Revised: 2002.

Objectives:Objectives:

Acceptable Standard of Good Health in India.Acceptable Standard of Good Health in India.

Increase Access to Decentralized Public Health System.Increase Access to Decentralized Public Health System.

Establishing New Infrastructure in the Existing Institutions.Establishing New Infrastructure in the Existing Institutions.

More Equitable Access to Health Services across Entire Country.More Equitable Access to Health Services across Entire Country.

Priority - Preventive & First Line Curative initiatives - Primary Health Level.Priority - Preventive & First Line Curative initiatives - Primary Health Level.

Emphasis – Rational Use of Drugs & Target – Burden able Diseases – TB, Malaria, Blindness, HIV/AIDS, Emphasis – Rational Use of Drugs & Target – Burden able Diseases – TB, Malaria, Blindness, HIV/AIDS, MCH - Problems.MCH - Problems.

Objectives of NHPObjectives of NHP To achieve an acceptable standard of To achieve an acceptable standard of

good health amongst the general good health amongst the general population of the country;population of the country;

To increase access to the decentralized To increase access to the decentralized public health system by establishing public health system by establishing new infrastructure in deficient areas, new infrastructure in deficient areas, and by upgrading the infrastructure in and by upgrading the infrastructure in the existing institutions.the existing institutions.

To ensuring a more equitable access to To ensuring a more equitable access to health services across the social and health services across the social and geographical expanse of the countrygeographical expanse of the country

To increase the aggregate public health To increase the aggregate public health investment through a substantially investment through a substantially increased contribution by the Central increased contribution by the Central GovernmentGovernment

To strengthen the capacity of the public To strengthen the capacity of the public health administration at the State level health administration at the State level to render effective service deliveryto render effective service delivery

To enhance the contribution of the To enhance the contribution of the private sector in providing health private sector in providing health services for the population group services for the population group which can afford to pay for serviceswhich can afford to pay for services

To rationalize use of drugs within the To rationalize use of drugs within the allopathic system; andallopathic system; and

To increase access to tried and tested To increase access to tried and tested systems of traditional medicinesystems of traditional medicine

History of NHPHistory of NHP Bhore committee 1943 Bhore committee 1943 Necessity of sound information system as a support to Necessity of sound information system as a support to

various development activitiesvarious development activities NHP 1983NHP 1983 Appropriate decision making and program planning is Appropriate decision making and program planning is

not possible without establishing a sound HMIS and not possible without establishing a sound HMIS and nationwide organizational set up is a must to procure nationwide organizational set up is a must to procure essential health information to support local essential health information to support local management of healthcare and effective management of healthcare and effective decentralization of the activitiesdecentralization of the activities

Health Policies / NHPHealth Policies / NHP Old wine in new bottleOld wine in new bottle Bottom up policy planning not Bottom up policy planning not

therethere Ground realities not taken into Ground realities not taken into

accountaccount Importance of HMIS is knownImportance of HMIS is known New programmes are createdNew programmes are created

Health PoliciesHealth Policies Policy makers and implementation managers Policy makers and implementation managers

never sit together to design one programme.never sit together to design one programme. In-coordination, Top down policyIn-coordination, Top down policy Lack of leadership, team spirit, lack of Lack of leadership, team spirit, lack of

dedication, speed money etc. are some reasons dedication, speed money etc. are some reasons for non-implementationfor non-implementation

NHP 1983 – Ambitious & Holistic goal was set NHP 1983 – Ambitious & Holistic goal was set to achieve HFA / 2000 AD through universal to achieve HFA / 2000 AD through universal provision of comprehensive preliminary health provision of comprehensive preliminary health care services, unable to achieve goals.care services, unable to achieve goals.

Data AgenciesData Agencies

Central Bureau of Health intelligenceCentral Bureau of Health intelligence Statistics division of H & FW departmentStatistics division of H & FW department Sample Registration SchemeSample Registration Scheme Civil Registration SchemeCivil Registration Scheme State level State level HMIS version 1.0 1983 – 85HMIS version 1.0 1983 – 85 HMIS version 2.0 1996HMIS version 2.0 1996

National Policies related to National Policies related to healthhealth

1.1. National Health Policy 2002National Health Policy 2002

2.2. National Population Policy 2000National Population Policy 2000

3.3. National AIDS Prevention and Control National AIDS Prevention and Control Policy 2002Policy 2002

4.4. National Blood Policy 2002National Blood Policy 2002

5.5. National Policy for the Empowerment of National Policy for the Empowerment of Women (2001)Women (2001)

6.6. National Policy and Charter for National Policy and Charter for Children 2003Children 2003

7.7. National Youth Policy 2003National Youth Policy 2003

8.8. National Policy for Old Person National Policy for Old Person 19991999

9.9. National Nutrition Policy 1993National Nutrition Policy 1993

10.10. National Health Research Policy National Health Research Policy DraftDraft

1111 National Policy on EducationNational Policy on Education

1212 National Pharmaceutical PolicyNational Pharmaceutical Policy

1313 National Water PolicyNational Water Policy

1414 National Environment Policy National Environment Policy 20062006

1515 National Housing and Habitat National Housing and Habitat Policy 1998Policy 1998

National Health Policy: IndiaNational Health Policy: IndiaGoals:Goals: Eradicate Polio & Yaws – 2005.Eradicate Polio & Yaws – 2005.

Eliminate Leprosy – 2005.Eliminate Leprosy – 2005.

Eliminate Kala –azar – 2010.Eliminate Kala –azar – 2010.

Eliminate Lymphatic Filariasis – 2015.Eliminate Lymphatic Filariasis – 2015.

Achieve zero level growth – HIV/AIDS – 2007.Achieve zero level growth – HIV/AIDS – 2007.

Reduce Mortality by 50 % - TB, Malaria & other – Vector – borne, Water borne Diseases – 2012.Reduce Mortality by 50 % - TB, Malaria & other – Vector – borne, Water borne Diseases – 2012.

Reduce Prevalence of Blindness – 0.5% - 2010.Reduce Prevalence of Blindness – 0.5% - 2010.

Reduce IMR to 30/1000 & MMR to 1/1000 Live Births – 2010.Reduce IMR to 30/1000 & MMR to 1/1000 Live Births – 2010.

Increase Utilization of Public Health Facilities from current level of < 20% to > 75% - 2010.Increase Utilization of Public Health Facilities from current level of < 20% to > 75% - 2010.

Establish an Integrated System of Surveillance, National Health Accounts & Health Statistics – 2005.Establish an Integrated System of Surveillance, National Health Accounts & Health Statistics – 2005.

Increase Health Expenditure by Government as a % of GDP from the existing 0.9% to 2.0% - 2010.Increase Health Expenditure by Government as a % of GDP from the existing 0.9% to 2.0% - 2010.

Increase Share of Central Grants to Constitute at least 25% of Total Health Spending & Further Increase Share of Central Grants to Constitute at least 25% of Total Health Spending & Further Increase to 8% of the budget – 2010. Increase to 8% of the budget – 2010.

Increase State Sector Health Spending from 5.5% to 7 % of the budget – 2005.Increase State Sector Health Spending from 5.5% to 7 % of the budget – 2005.

Goals to be Achieved by 2000-2015Goals to be Achieved by 2000-2015

20032003

Enactment of legislation for regulating Enactment of legislation for regulating

minimum standard in Clinical Establishment andminimum standard in Clinical Establishment and

Medical InstitutionsMedical Institutions

20052005

Eradicate Poliomyelitis and YawsEradicate Poliomyelitis and Yaws

Eliminate LeprosyEliminate Leprosy

Establish an integrated system for surveillance,Establish an integrated system for surveillance,

National Health Accounts and Health StatisticsNational Health Accounts and Health Statistics

20052005

Increase State Sector Health spending from 5.5% toIncrease State Sector Health spending from 5.5% to

7% of the budget7% of the budget

1% of the total health budget for Medical Research1% of the total health budget for Medical Research

Decentralization of implementation of public healthDecentralization of implementation of public health

programsprograms

20072007

Achieve Zero level growth of HIV/AIDsAchieve Zero level growth of HIV/AIDs

Eliminate Kala AzarEliminate Kala Azar

20102010

Eliminate Kala AzarEliminate Kala Azar

Reduce Mortality by 50% on account of TB, MalariaReduce Mortality by 50% on account of TB, Malaria

and other Vector and Water Borne diseasesand other Vector and Water Borne diseases

Reduce Prevalence of Blindness to 0.5%Reduce Prevalence of Blindness to 0.5%

Reduce IMR to 30/1000 and MMR to 100/LakhReduce IMR to 30/1000 and MMR to 100/Lakh

Increase utilization of public health facilities fromIncrease utilization of public health facilities from

current level of <20 to >75%current level of <20 to >75%

20102010Increase health expenditure by GovernmentIncrease health expenditure by Governmentfrom the existing 0.9% to 2.0% of GDPfrom the existing 0.9% to 2.0% of GDP2% of the total health budget for Medical2% of the total health budget for MedicalResearchResearchIncrease share of Central grants to constituteIncrease share of Central grants to constituteat least 25% of total health spendingat least 25% of total health spendingFurther increase of State Sector healthFurther increase of State Sector healthspending to 8%spending to 8%20152015Eliminate Lymphatic FilariasisEliminate Lymphatic Filariasis

NHP : Implementation – Gaps:NHP : Implementation – Gaps:

Process of Health Information System. Process of Health Information System.

Health Data –Input,Health Data –Input,

Recording,Recording,

Storing, Storing,

Retrieving,Retrieving,

Processing, Processing,

Out – put, Out – put,

Decision – Making Decision – Making

Administrative Systems.Administrative Systems.

Routine Service Reporting.Routine Service Reporting.

Vital RegistrationVital RegistrationEpidemiological Surveillance.Epidemiological Surveillance.Specific Program Reporting.Specific Program Reporting.

SWOT AnalysisSWOT Analysis

StrengthStrength Policy identify many gross deficiencies of Policy identify many gross deficiencies of

the existing healthcare scenario, proposes a the existing healthcare scenario, proposes a substantial changes. Justification provided substantial changes. Justification provided for the new policy are convincing and for the new policy are convincing and attempt to accelerate achievement for the set attempt to accelerate achievement for the set public health goalspublic health goals

Commitment to enhance the budget on Commitment to enhance the budget on health expenditure from 5.2% to 6% health expenditure from 5.2% to 6% of GDP with the government of GDP with the government contribution increasing from 0.9% to contribution increasing from 0.9% to 2% by 2010/2% by 2010/

Availability of advance technology Availability of advance technology and proven public health strategies.and proven public health strategies.

WeaknessWeakness

Lack of monitoring and evaluationLack of monitoring and evaluation Lack of Government expenditure on Lack of Government expenditure on

public healthpublic health Gap in situation analysis and policy Gap in situation analysis and policy

prescriptionprescription

OpportunityOpportunity

Based on past experience of National Health Based on past experience of National Health Policy 1983 and long history of Policy 1983 and long history of implementation of various programs, India implementation of various programs, India get this opportunity to move ahead in health get this opportunity to move ahead in health through Health Policy 2002through Health Policy 2002

Supportive environment and absence of Supportive environment and absence of obvious threat of war, unrest etc.obvious threat of war, unrest etc.

Policy initiative will provide a new impetus Policy initiative will provide a new impetus to the ‘development of the health sector’.to the ‘development of the health sector’.

ThreatsThreats Health tourism will drain the trained Health tourism will drain the trained

manpower to private sector and will manpower to private sector and will encourage privatization in absence of encourage privatization in absence of regulation on private sector for regulation on private sector for encouragement could be dangerous for the encouragement could be dangerous for the public health. However, policy proposes public health. However, policy proposes regulation of the private sector but how and regulation of the private sector but how and when is not described in detail. Private when is not described in detail. Private expenditure is already more in India as expenditure is already more in India as compare to other countries in the world.compare to other countries in the world.

Occurrence of unexpected natural calamities Occurrence of unexpected natural calamities and catastrophesand catastrophes

Negative involvement of religious Negative involvement of religious fundamentalists, for example polio sterility fundamentalists, for example polio sterility myth impending pulse polio program myth impending pulse polio program

Creation of a cadre of ‘half backed paramedical Creation of a cadre of ‘half backed paramedical doctors’ is strengthening quackerydoctors’ is strengthening quackery

Financial autonomy of district societies may Financial autonomy of district societies may lead to corruption and need to be put under lead to corruption and need to be put under strict outer regulation and accountabilitystrict outer regulation and accountability

IssuesIssues Too many registersToo many registers Too much repeat data collectedToo much repeat data collected Data missing / sorting not doneData missing / sorting not done Distance factor for collection of dataDistance factor for collection of data Grass root health workers ANM is the Grass root health workers ANM is the

main person – too many registers for main person – too many registers for herher

Staff involved to be aware of need Staff involved to be aware of need for appropriate and timely for appropriate and timely information to understand how to information to understand how to use it effectively.use it effectively.

Health workers are required to Health workers are required to maintain large number of registersmaintain large number of registers

Data generated rarely used as basis Data generated rarely used as basis for management decisions.for management decisions.

MeetingsMeetings PHC monthly meetings – routinePHC monthly meetings – routine Data generated by health workers Data generated by health workers

not disseminated / discussed or not disseminated / discussed or used in decision making / policyused in decision making / policy

Data transferred to THO – DHO – Data transferred to THO – DHO – NIC – State HQ - GOINIC – State HQ - GOI

New Outcomes / Indicators created New Outcomes / Indicators created based on funding by based on funding by WB/UNICEF/DFID etc.WB/UNICEF/DFID etc.

IPP-9 Evaluation – Role of ANMsIPP-9 Evaluation – Role of ANMs Search Surveys / SRS/CRS/ NHFs Search Surveys / SRS/CRS/ NHFs

all conducted but none give all conducted but none give detailed comprehensive complete detailed comprehensive complete data in given time – on time – data in given time – on time – delayed reportsdelayed reports

Secretariat system of governance Secretariat system of governance Planning and Monitoring as central activityPlanning and Monitoring as central activity H and FW administration centralized H and FW administration centralized Lack of awareness by policy makers the Lack of awareness by policy makers the

strategic importance of HMISstrategic importance of HMIS No of programmes , surveys with no ground No of programmes , surveys with no ground

realities using the same HFW staffrealities using the same HFW staff

Multiplicity of institutions collecting data Multiplicity of institutions collecting data Fragmented Data collectedFragmented Data collected Some programmes have their own data Some programmes have their own data

collection sysytemscollection sysytems Vertical programmes own HMISVertical programmes own HMIS Lack of effective coordination resulting in Lack of effective coordination resulting in

duplication and gaps in data collectionduplication and gaps in data collection

Exhaustive information collected but rarely Exhaustive information collected but rarely usedused

PHC monthly report PHC monthly report ANM fills up many formsANM fills up many forms Mostly incomplete , unreliable and unused non Mostly incomplete , unreliable and unused non

collatable data hardly used by planners and at collatable data hardly used by planners and at local level for decision makinglocal level for decision making

No verification of dataNo verification of data

Only Aggregates are sent to higher levelsOnly Aggregates are sent to higher levels Details missed by policy makers /plannersDetails missed by policy makers /planners Reliability of dataReliability of data Data collected by bilateral agencies and Data collected by bilateral agencies and

multilateral agencies are different from govt. multilateral agencies are different from govt. data : Project assessment and viability data : Project assessment and viability becomes difficult becomes difficult

National Health Policy: IndiaNational Health Policy: IndiaNational Health Policy: India: Implementation – Gaps: Bridging:National Health Policy: India: Implementation – Gaps: Bridging:

Technical Inputs – Public Private PartnershipTechnical Inputs – Public Private Partnership

Process of Health Information System. Process of Health Information System. Health Data –Input,Health Data –Input, Recording,Recording, Storing, Storing, Retrieving, Retrieving, Processing, Processing, Out – put, Out – put, Decision – MakingDecision – Making Administrative Systems.Administrative Systems. Routine Service Reporting.Routine Service Reporting. Vital RegistrationVital Registration Epidemiological Surveillance.Epidemiological Surveillance. Specific Program Reporting.Specific Program Reporting.

SWOT Analysis – National SWOT Analysis – National Population PolicyPopulation Policy

StrengthStrength Formulation of National Policy by the Health Formulation of National Policy by the Health

Ministry involving Planning Commission and Ministry involving Planning Commission and CabinetCabinet

Policy is passed by the parliamentPolicy is passed by the parliament Well planned and drafted after many Well planned and drafted after many

deliberations particularly Swaminathan deliberations particularly Swaminathan Committee and National health Policy 1983Committee and National health Policy 1983

Long experience of National Family Welfare Long experience of National Family Welfare ProgramProgram

WeaknessWeakness Some of the goals and targets are Some of the goals and targets are

unrealisticunrealistic Many failures in achieving targets in the Many failures in achieving targets in the

pastpast Lack of community involvementLack of community involvement Lack of resources and poor budgetingLack of resources and poor budgeting Lack of well planned monitoring and Lack of well planned monitoring and

evaluationevaluation

OpportunityOpportunity Provision of Research in RCH and Provision of Research in RCH and

Contraceptive that will handle the increasing Contraceptive that will handle the increasing demanddemand

Integrated approach involving mother, Integrated approach involving mother, adolescent, and child in the area of nutrition, adolescent, and child in the area of nutrition, health, education, involving other systems of health, education, involving other systems of medicine etc.medicine etc.

Decentralization and more autonomy for better Decentralization and more autonomy for better implementationimplementation

Provision of legislation act as disincentive Provision of legislation act as disincentive for large family size for legislature and for large family size for legislature and councilors. Strict enforcement of Child councilors. Strict enforcement of Child Marriage Restraint Act and Pre-Natal Marriage Restraint Act and Pre-Natal Diagnostic Act is also providedDiagnostic Act is also provided

Adequacy of funding assured.Adequacy of funding assured.

ThreatThreat Reviving system of licensed medical practitioners may Reviving system of licensed medical practitioners may

not be supported by Indian Medical Association and not be supported by Indian Medical Association and other professional bodiesother professional bodies

Flexibility in NGOs functioning may give rise to more Flexibility in NGOs functioning may give rise to more corruption and compromise in the achievement of corruption and compromise in the achievement of targetstargets

Cash incentive and heavy dependency on health care Cash incentive and heavy dependency on health care providers in government system would compromise the providers in government system would compromise the quality and increase financial burden.quality and increase financial burden.

More encouragement to private sector will make the More encouragement to private sector will make the India the most privatized health system in the worldIndia the most privatized health system in the world

RecommendationRecommendation

Reform health information systemReform health information system Transition from reporting system to conscious use of Transition from reporting system to conscious use of

informationinformation Managerial decision makingManagerial decision making Accuracy of Data Accuracy of Data Facility wise performanceFacility wise performance New computerized HIMS is expected to increase New computerized HIMS is expected to increase

coverage & improve quality of servicescoverage & improve quality of services

The vision of a new HMIS is that it should be The vision of a new HMIS is that it should be simple to operate & valuable to health staff.simple to operate & valuable to health staff.

The system is designed in such a way thatThe system is designed in such a way thathealth workers who collect the information must health workers who collect the information must be able to use it also. The forms & formats be able to use it also. The forms & formats developed should not be too many, bulky and developed should not be too many, bulky and complicated so as to avoid the temptation of not complicated so as to avoid the temptation of not filling them.filling them.

HMIS to be meaningful must beHMIS to be meaningful must be

understoodunderstood

from ANM to Health Secretary from ANM to Health Secretary

andand

Implemented and Utilized forImplemented and Utilized for

delivery of quality health caredelivery of quality health care

IHMR BANGALOREIHMR BANGALORE