National Rural Health Mission NRHM Review Meeting with

National Rural Health Mission (NRHM) Review Meeting with State’s Health Secretaries, Mission Directors & Directors of Health Services 11 th& 12 th Sept. 2012 --- JS (Policy) 1

ACHIEVEMENTS, SO FAR… • MMR (212 as per RGI report 2007 -09) – Annual Rate of decline between 2004 -06 and 2007 -09 is 23% higher than annual rate of decline between 19992001 and 2004 -06 – EAG States showed a decline of 67 points in MMR (in 2007 -09 compared to 2004 -06) against a National Decline of 42 points Status of Drop in MMR (in points) from 2004 -06 to 2007 -09 Assam U P/Uttarakhand Rajasthan M P/Chhattisgarh Bihar/Jh. Orissa INDIA Karnataka Haryana Maharashtra Punjab Andra Pradesh TN Kerala Gujarat 9 81 0 70 66 51 45 42 35 33 26 20 20 14 14 12 0 10 20 30 40 50 60 70 280 90

ACHIEVEMENTS, SO FAR… • IMR reduced from 58 in 2005 to 47 as per SRS 2010 – Rate of Decline of IMR accelerated by 29 % between 2005 -10 as compared to 2000 -2005 – Decline in Rural IMR and U 5 MR is higher than the decline in urban areas, thereby narrowing the Rural - Urban Gap – Decline of U 5 MR & IMR is more in EAG States • India has remained free of Wild Polio for more than a year 3

ACHIEVEMENTS, SO FAR… TFR declined to 2. 5 in 2010 as against 2. 9 in 2005 Category State Bihar UP Very High Focus MP states for FP Rajasthan Jharkhand Chhattisgarh SRS-2005 SRS-2010 Point Change 4. 3 4. 2 3. 6 3. 7 3. 5 3. 4 3. 7 3. 5 3. 2 3. 1 3. 0 2. 8 -0. 6 -0. 7 -0. 4 -0. 6 -0. 5 -0. 6 All India 2. 9 2. 5 0. 4 • Nationally Rate of Decline of TFR between 2005 -2010 increased by 47 % as compared to 2000 -2005 • All the 6 very high focus states have shown a decline equal to or better than All India average • Steepest decline in annual growth rate from 1. 97 to 1. 64 since 4 independence

ACHIEVEMENTS, SO FAR… Disease Control Programmes Malaria Mortality Reduction Rate 55% mortality reduction in malaria in 2010 as against 2006 Dengue Mortality Reduction Rate 26% mortality reduction in dengue in 2010 as against 2006 More than 60 Lakh Cataract Operations every year Reduced from 1. 8 per 10000 in 2005 to less Leprosy Prevalence Rate than 1 per 10000 Cataract operations Tuberculosis 73% case detection rate and 88% Cure rate 5

STRENGTHENING OF HEALTH SYSTEMS/ SERVICES - PROGRESS • Over 1. 5 lakh Human Resource added (on a baseline of 2. 17 lakh) • 2315 Referral Hospitals strengthened to act as First Referral Units (FRUs) with capacity to provide comprehensive obstetric emergency care • 8475 PHCs upgraded as 24 x 7 PHCs • 2012 Mobile Medical Units (MMUs) provided in 449 districts for delivery of health care in difficult areas • 7218 Emergency Response / basic ambulance service vehicles • Nation-wide system of HMIS and MCTS set up to ensure and monitor health interventions 6

HOWEVER…

SHORT FALL OF DOCTORS, SPECIALISTS AND NURSING STAFFS (IN PERCENTAGE OF TOTAL REQUIREMENT) SHORT FALLS OF DOCTORS IN PHCs AND SPECIALISTS IN CHCs 58% SOURCE: RHS 2011 A IN DI P M AR OD I GU J JH A CH A 35% 80% 70% 60% 50% 40% 30% 20% 10% 0% 73% 64% 72% 63% 60% 23% U OD P IS HA UT TA DE RA LH CH KH I AT AN D TI SG AR H IN DI A 68% 65% 64% 63% 62% U 80% 70% 60% 50% 40% 30% 20% 10% 0% SHORT FALL OF NURSING STAFFS IN PHC AND CHC

SHORT FALL OF PARAMEDICS AND MPW (In % of total requirement) SHORT FALL OF MPW (MALE) IN SUB CENTERS 120% 100% 92% 89% 100% 86% 80% 65% 60% SOURCE: RHS 2011 40% 20% A IN DI K HP J& DE DU LHI CH ER PU Y NJ AB 0% PO AN DH RA PR MP AD ES H IN DI A HP B W BI HA R SHORT FALL OF PARAMEDICS IN CHCS 100% 92% 90% 82% 80% 70% 57% 56% 60% 50% 42% 40% 30% 20% 10% 0%

INFRASTRUCTURE STRENGTHENING- I New Construction (Completion Rate < 30%) SUB CENTRE (SC) PRIMARY HEALTH CENTER (PHC) COMMUNITY HEALTH CENTER (CHC) DISTRICT HOSPITAL (DH) • J&K, CHATTISHGARH • ANDHRA PRADESH, W. BENGAL, MAH. , TN, DELHI • JHARKHAND, ODISHA, UTTARAKHAND, • ARUNACHAL PRADESH, MEGH. , NAGALAND, TRIPURA • KERALA, W. BENGAL, HARYANA, KARNATAKA, MAHARASHTRA, UTTARAKHAND, UP • NAGALAND, ASSAM, MIZORAM • KERALA • ODISHA, UTTARAKHAND, J&K

INFRASTRUCTURE STRENGTHENING- II Renovation And Up gradation SUB CENTER (SC) (Completion Rate < 30%) • CHHATTISGARH, J&K, UTTARAKHAND • ARUNACHAL PRADESH, SIKKIM • A&N ISLANDS • CHATTISHGARH, JAMMU & KASHMIR, SIKKIM PRIMARY HEALTH CENTER (PHC) • ANDAMAN & NICOBER , CHANDIGARH, DELHI, PODUCHERRY COMMUNITY HEALTH CENTER(CHC) • BIHAR, J&K, MANIPUR, GOA, WEST BENGAL • A&N ISLANDS, DELHI DISTRICT HOSPITAL (DH) • UP, J&K, MANIPUR, NAGALAND, ANDHRA PRADESH, HARYANA, KERALA, WEST BENGAL • A&N ISLANDS, CHANDIGARH, DELHI

CONSTITUTION OF VILLAGE HEALTH SANITATION AND NUTRITION COMMITTEE (VHSNC) 100% 93% PERCENT OF VHSNC CONSTITUTED OUT OF TOTAL VHSNC REQUIRED 80% 97% 98% 72% 70% 60% 50% 49% 50% 54% 40% 30% 20% 16% 10% ra m M izo t ja ra Gu n ha ja st ar k Ra ha n d A DI IN P M . ad Pr u. Ar Jh La ks hd w ee p UP HP 0% SOURCE: RHS 2011

STRENGTHENING HEALTH INSTITUTIONS- I (24 X 7 PHCs) 120% 96% 100% States with less than 50% of total 77% PHCs as 24 X 7 PHCs 100% 80% 60% 35% 40% 20% 19% 14% 13% 10% 4% Ta m u ad il N kim Sik rry du c he a ur Pu Tr ip A DI IN t. B en ga l d W es kh an h ar Jh Ch at tis g ar i lh De h es ad Pr Ut ta r Or iss a 0%

STRENGTHENING HEALTH INSTITUTIONS- II (FRUs) States with less then 50% of DH, SDH &CHC as FRUs 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 91% 92% 69% 71% 55% 36% Hi m M an Jh ipur ar kh ac a ha l P nd A rad e & N sh Isl M and e s M ad gha Ar hya laya un P ac rad ha e l P sh ra de sh An dh IN ra DIA Pr ad e Ta m sh il N Ja Pud adu m m uch u & erry Ka sh m ir Pu nj ab 4% 18% 19% 14% 11% 13%

Action Plan for the Year 2012 -13

STATES WITH CUSHION MORE THAN Rs 10 Crores 10000 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 474, 41 In Crores 113, 41 185, 74 134, 64 53, 52 31, 58 35, 72 46, 04 92, 34 RESOURCE ENVELOPE AMOUNT APPROVED CUSHION AVAILABLE im kk Si i lh De CH Ka rn at al a TN B W m sa As An dh ra P. r ha Bi UP 12, 4

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK 1. Rational deployment of HR with the highest priority accorded to high focus districts and delivery points (Non compliance would lead to reduction of up to 7½ %) Conditionalities and incentives Progress by the State 1. 1 Rational deployment policy including- Posting of staff on the basis of case load, rational deployment of specialists, priority to HF districts In place by October, 2012 % incentive/ Disincentive Otherwise, deduction of 2% of MFP Minimum for all delivery Otherwise, 1. 2. 1 Preparation of baseline data for points and SCs in high deduction of HR focus districts; by Nov 2% of MFP. 2012 90% of all delivery points Otherwise, 1. 2. 2 Evidence of corrective action in staffed as per norms, deduction of line with the policy 90% of all SCs in high 2% and 1. 5% focus districts should of MFP have at least one ANM respectively. Method of verification Policy notification ; Website posting and state report State report; website posting by December 2012.

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK 2. Facility wise performance audit and corrective action based thereon. (Non compliance would lead to reduction of up to 7 ½% of MFP) Conditionalities and incentives 2. 1. 1 Range of services (as in MNH guidelines for RCH services, OPD, IPD and other services to be determined by the State) specified at least for delivery points 2. 2. 1 Facility wise reporting on HMIS portal by all priority facilities/delivery points for October( SC data if needed be uploaded from PHC) 2. 2. 2 Corrective action (priority to be given to high focus districts) based on facility wise reporting. Progress by the State % incentive/ Disincentive Method of verification State report and Up to 2½ % of Website posting By September, 2012 MFP by September, 2012 State report ; Up to 2½ % of State HMIS By November, 2012 MFP October data to be uploaded by November State reports on By November, 2012 Up to 2½ % of corrective action MFP by Nov, 2012.

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK 3. Gaps in implementation of JSSK (May lead to a reduction in outlay upto 10% of RCH base flexi-pool) Conditionalities and incentives Progress by the State % incentive/ Disincentive 3. 1. 1 Government order for coverage of entire State regarding JSSK By Sept’ 2012 Upto 2½% of RCH base flexi-pool 3. 2. 1 State wide dissemination of GO/policy, By Oct’ visible IEC in facilities and community 2012 awareness Method of verification Copy of GO ; Website posting Sample Up to 2½% of RCH community visits base flexi-pool 3. 2. 2 No user charges. Free Drugs, By Oct’ diagnostics, diet. Grievance redressal system 2012 operational Upto 2½% of RCH base flexi-pool Field visits; exit interviews grievance redressal records. 3. 2. 3 At least 50% of pregnant women and sick newborns coming in should be using By Nov’ assured and cashless means of transport- 2012, and getting a similar drop back home Upto 2½% of RCH base flexi-pool -do-

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK 4. Continued support under NRHM for 2 nd ANM would be contingent on improvement on ANC coverage and immunization as reflected in MCTS. Vaccines, logistics and other operational costs would also be calculable on the basis of MCTS data Conditionalities and incentives Progress by the State Method of verification 4. 1 Increase in ANC coverage ( first ANC and full ANC) as per MCTS data in (1) State (2) High Focus districts Increase in April. MCTS website ; state December 2012 over report by January, 2013 the same period last year 4. 2 Increase in full immunization as per MCTS data in (1) State (2)High Focus districts Increase in April. MCTS website ; state December 2012 over report by January, 2013 the same period last year

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK 5. Responsiveness, transparency and accountability ( incentive upto 8% of MFP) Conditionalities and incentives 5. 1 Demonstrated including innovations for responsiveness in particular to local health needs e. g use of epidemiological data, active participation of public representatives in DHS / RKS meetings , etc. 5. 2 Demonstrated evidence/innovation for transparency e. g. mandatory disclosures and other important information including HR posting etc. to be displayed in the State NRHM websites etc. Progress by the % incentive/ State Disincentive Innovation implemented and impact demonstrated; State to send brief report in format suggested by November, 2012. ( one 5. 3 Demonstrated evidence/innovation for innovation in accountability: e. g. initiatives in community each of the monitoring, Jan sunwai etc three areas) Method of verification State report (format in Up to 8% of Annex 1) by MFP November, 2012 ; state visits for rapid appraisal

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK 6. Quality assurance (incentive upto 3% of MFP) Conditionalities and incentives 6. 1. 1 States notify policy/strategy (align to policy) as well as standards quality national 6. 2. 1 Constitute dedicated teams. Training of state and district quality team and DH quality team completed 6. 2. 2 Current levels of quality measured for all “priority facilities” and scored and available on public domain. Deadlines for each facility to achieve quality standards declared Progress by the State % incentive/ Disincentive In place by November 2012 Up to 3% of MFP State team trained by November 2012 Method of verification Notification and state report by November, 2012 Quality scores of all priority facilities available in public domain

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK 7. Inter-sectoral convergence (incentive upto 3% of MFP) Conditionalities and incentives Progress by the State % incentive/ Disincentive Method of verification 7. 1. 1 Implementation frame work for intersectoral convergence with allied sectors/departments State report By Up to 1% of (copy of November MFP implementation 2012 framework ) 7. 2. 1 convergence identified with education, etc. initiated. By Up to 2% of Government November MFP order , State 2012 report Intersectoral opportunities WCD, PHED, and action

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK 8. Recording of vital events including strengthening of civil registration of births and deaths (incentive upto 2% of MFP). Conditionalities and incentives 8. 1 A strategy paper identifying reasons and the road map for increasing registration 8. 2 Death reports with cause of death (especially any under 5 child or any woman in 15 to 49 age group) shared with district health team on monthly basis. Progress by the State By October 2012 By November 2012 % incentive/ Disincentive Method of verification Strategy Up to 1% of document MFP and policy statement. Death reports Up to 1% of received at MFP district level - verified in sample of districts.

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK 9. Creation of a public health cadre (by states which do not have it already) (incentive upto 10% of MFP) Conditionalities and incentives 9. 1. 1 Stated policy and road map (including career path on creation of a public health cadre) 9. 2. 1 Notification for creation of public health cadre Progress by the State % incentive/ Disincentive Policy & road map in place by November , 2012 State report Up to 4% of website MFP posting by November , 2012 Government order in place. Method of verification Website Up to 6% of posting / MFP state report

CONDITIONALITIES: IMPLEMENTATION FRAMEWORK 10. Policy and systems to provide free generic medicines to all in public health facilities( incentive upto 5% of MFP ) Conditionalities and incentives Progress by the State 10. 1. 1 Clear policy articulation of free By October generic medicines to all in public health 2012 facilities 10. 2. 1 EDLs finalised and drug formulary By published and made available in all public November health facilities 2012 10. 2. 2. Overall procurement and logistics strategy in place. Detailed design and plan By for rate contracting, regular stock up November dates, indent management, warehousing, 2012 promotion of rational drug use, contingency funds with devolution of financial powers etc. in place. % incentive/ Disincentive Method of verification Website Upto 2% of posting / state MFP report Notification/ Publication/ Web posting Up to 3% of State report/ MFP strategy document

Responsiveness, transparency and accountability Format for state report State to provide a brief write up (<3 pages) on the best practice on Responsiveness, transparency and accountability separately Suggested structure: – Background: (Elaborate on the problem, which the innovation seeks to address; and in particular, provide details of target group/ base line data, if available) – Description of the innovation: (Including date of commencement and current status; coverage in terms of districts/ blocks/ villages; overall approach / strategy; implementation/ institutional arrangements; whether pilot / scaled up) – Costs: (Broad break up of one-time and recurring costs; assessment of cost effectiveness) – Sustainability: (Assess organisational and financial sustainability and approach to ensuring the same) – Outcome: (Extent to which base-line conditions have improved; results of third party evaluations, if carried out)

Thank You