NRHM

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• NRHM

Meeting Peoples Health Needs
21st October 2008 UN/ISRO India Regional
Workshop on Using Space Technology for Tele
Epidemiology to benefit Asia and the Pacific
Regions National Rural Health Mission Ministry
of Health Family Welfare Government of India
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• India an overview
• Structure of Health Sector
• Status of Health
• Health Sector Rejuvenation
• NRHM Brief outline
• eHealth Brief outline
• Technabling the NRHM
• Really beyond the existing mandate of Group 6.
  However, Public Health is the central theme and
  sat tech is an important tool for the same. Group
  6 may decide to realign its mandate in view of
  the ground realities in developing countries.

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• We turned
• Billionaire seven
• years ago

Were now over1.1 Billion
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States UTs287
India - Overview
Villages 6,00,000
Blocks6500
District615
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States UTs287
Administration Overview
Villages 6,00,000
Gram Sabha
Panchayat (Local Self Govt)
Block Panchayat
Blocks6500
Zila Parishad
Municipalities, Cantonment Boards, Corporations,
Town Area Commtt etc
District615
State Legislature
National Parliament
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States UTs287
Health Sector (Public) Overview
Villages 6,00,000
Health Sub-centre 1,45,000
Primary H Centre 22,370
Blocks6500
Community Health Centre 4045
District Hospitals 585
District615
Sub Divisional, Taluk , Civil , TB etc
Tertiary centres, medical colleges, GoI Hospitals
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• Structure of
• Health sector
• in India

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Health delivery apparatus

• Public Sector facilities
• Private Practitioners
• ESI, CGHS, PSU Hospitals
• Railways Hospitals
• Armed Forces Medical Services
• Corporate Hospitals
• Indian System of medicine
• Informal providers
• Quacks/Crooks magico religious practitioners

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Sub-Centre (SCs) Most peripheral contact point
with primary health system One ANM and one Male
Health Worker One Lady Health Worker (LHV)
supervises six Sub-Centres. Tasks relating to
interpersonal communication wrt maternal and
child health, family welfare, nutrition,
immunization, diarrhea control and control of
communicable diseases programmes. Provided
with basic drugs 100 Central assistance to all
the Sub-Centres since April 2002 There are
1,45,272 Sub Centre as on March, 2007
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Primary Health Centre (PHCs) First contact point
with Medical Officer. Envisaged to provide an
integrated curative and preventive
care Established and maintained by the State
Governments under the Minimum Needs Programme
(MNP) Manned by a Medical Officer supported by
14 paramedical and other staff. It acts as a
referral unit for 6 Sub Centres. It has 4 - 6
beds for patients. There are 22,370 PHCs as on
March, 2007 in the country
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Community Health Centre (CHCs) Established and
maintained by the State Government under MNP/BMS
programme . It is manned by four medical
specialists i.e. Surgeon, Physician,
Gynecologist and Pediatrician supported by 21
paramedical and other staff. It has 30 in-door
beds with one OT, X-ray, Labour Room and
Laboratory facilities. It serves as a referral
centre for 4 PHCs and also provides facilities
for obstetric care and specialist consultations.
As on March, 2007, there are 4045 CHCs
functioning.
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Structure of Public Health System

• Health is a State Subject Family Welfare is
  Concurrent.
• Primary Health care is Local self Government.
• Most institutions and manpower are state
  property.
• Most programmes are in the central initiatives.
• National Programmes address only 25 of all
  morbidities.
• .59 doctors, 0.8 nurses and 0.47 Midwives per
  1000 population
• 1.86 health worker /1000
• No dedicated health functionary at village level.
• First functionary at Sub Centre level (5000
  population)
• First doctor only at PHC (30,000 population)
• First specialist only at CHC (80,000 population)

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Deep rooted structural issues

• Sustainable Systems
• Financing 5.2 of GDP ( Private 4.3 , Public
  0.9)
• Infrastructure (over 2,00,000 facilities yet
  inadequate)
• Human Resources Workforce Issues Irrational
  distribution Poor work culture
  absenteeism Poor supervision
• Logistics, Management and Evaluations
• Equity and accountability
• Non responsive to citizens

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• Statistics of
• Health sector
• in India

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Indias survival challenge

• Birth rate 24.1 (2004)
• 27 million neonates to take care
• U5MR 95 (1998-99)
• 2.5 million die before completing 5 years
• Globally India accounts for 23 of all U deaths
• IMR 57 (2007)
• 1.6 million die before completing 1 year
• 64 of infant deaths occur in the first 30 days.
• NMR 40 (2002)
• 1.1 million die before 4 weeks of age
• Demographic transition
• If born in 2007 will live till 64 years old. 60
  years ago expect to die at 32 years
• 2nd largest number of elderly (60)
• 24 million over 60 in 1961 to 77 million in 2001.
• 17.5 India will be over 60 in 2050 (7.5 in
  2001).

 
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H R Density / 1000 Population ( World
Health Statistics - 2007 W H O )

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National goals MDG context
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Indias Health Indicators
Large inter state variations
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• Rapid economic growth
• Over past 16-17 years of reform.
• Poverty incidence fallen
• About 36 in 93-94 to 28 in 04-05
• Educational opportunities have increased.
• Little Improvement in Child malnutrition
• Among the highest in world
• In some states it has got worse.
• Slow improvement in Health nutrition indicators
• General paucity of health infrastructure at the
  village level.
• Improved Immunization coverage
• 36 in 92-93 to 42 in 98-99 to 44 in 05-06.
• Actually fell (98-99 to 05-06) in Punjab, Haryana
  and Maharashtra.
• Sex ratios have got worse

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THE CITIZENS PERSPECTIVE
Lack of Holistic Approach Health not a
priority. Under funded, yet not
utilised. Shortage of infrastructure human
resources Lack of community ownership Lack
of accountability Lack of basic amenities food
drinking water Non integration of Disease
Control programmes Non responsiveness to Citizen
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• Something
• is changing
• in India

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• Average monthly patient attendance in PHCs in
  Bihar increased from 39 (per month) to over 3500
  (per month)
• Institutional delivery
• Assam from 107,000 during 01-02 to 138,000 during
  04 -05 then to 265,000 during 07-08
• Bihar from 7,233 during July 06 to 47 thousand
  during July 07
• MP from 41 during 05-06 to 62 during 07-08
• Gujarat from 57 during 04-05 to 76 during 07-08
• Tamil Nadu Between 2002-03 to 2008-09, deliveries
  at
• homes reduced from 9.9 to 1.11
• private facilities reduced from 39.9 to 34.64
• PHCs increased from 6.3 to 19.68
• (majority of this change being post 2005)

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Andhra Pradesh Toopran PHC
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Before
Andhra Pradesh Jinnaram PHC
After
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Sub Centre - Maharashtra
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Sub Centre - Maharashtra
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Neonatal Corner-Haryana
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Serving the Underserved
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IMPROVING DELIVERIES IN THE PHCs-TN
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AP Rural Emergency Health Transport

• Transport to pregnant women, infants, children
  emergencies.
• Toll-free No.108 365x24x7.
• 502 ambulances in 1107 mandals.
• Average time for reaching hospital 16 min. in
  Urban 22 min. in Rural areas.
• Total emergencies attended per day is 2,806 (97
  are Medical)
• In two years, REHTS has saved 20,394 lives by
  attending to them in the crucial Golden hour

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WORKS UNDERTAKEN THROUGH PATIENT WELFARE SOCIETY
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• What facilitated
• these changes ?

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National Rural Health Mission launched in April,
2005
Rejuvenate the Health delivery System Universal
Health Care Access Affordability Equity
Quality Reduce IMR, MMR,TFR Improve Disease
control Overarching umbrella for all programmes
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Goals of the Mission
Universal Health care, well functioning health
system. Reduce IMR to 30/1000 live births by
2012 Reduce MMR to 100/100,000 live births by
2012 TFR reduced to 2.1 by 2012 Reduce sustain
Malaria Mortality to 60 by 2012 Kala Azar
eliminated by 2010, Filaria reduced by 80 by
2010 Dengue Mortality reduced by 50 by 2012 TB
DOTS maintain over 70 case detection 85 cure
rate 46 lakh cataract operations annually by
2012. Upgrading all health facilities to IPHS.
Increase utilization of FRUs from 20 bed
occupancy to 75
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NRHM the recipe

• Over arching umbrella - sector wide life cycle
  approach
• Enhance funding to 2-3 GDP
• Architectural corrections in delivery system
  reform agenda
• Non negotiable service guarantees at all levels
• Backward computing of budgets for entitlements.
• Fund floats at local levels to kick start a
  rejuvenation
• Blend dedicated budgets with untied, Flexible
  funds
• Improve range-depth quality of monitoring.
• Community Health Worker
• Capacity Building

List ur Excuses and show them the door
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• The
• Paradigm
• Shift

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The Paradigm Shift

• Decentralised planning
• Outputs and Outcome based
• Pro-Poor Focus Equitable systems
• Quality of Care and the IPHS norms
• Rights based service delivery
• Pre stated entitlements at all levels
• Inputs computed as function of the entitlements
  and estimated patient load
• Judicious mix of dedicated budget lines - untied
  funds
• Monitor quality
• Community Participation

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The Paradigm Shift

• Bringing the public back into public health
• At hamlet level ASHA, VHSC, SHGs, Panchayats.
• At the facility level RKS
• At the management level health societies
• Governance reform
• Manpower, Logistics Procurement processes.
• Decision making processes
• Institutional design, Accountability framework
• Convergence
• Water and sanitation
• Nutrition
• Education

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Expanding Services at PHCsPHCs Operational 24 x 7
Non High Focus
High Focus
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Functional Referral ChainsFirst Referral Units
Non High Focus
High Focus
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Local Management of FacilitiesRogi Kalyan Samiti
High Focus
Non High Focus
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• The
• Strategies

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The Strategies

• Infrastructure upgradation
• Sub Centres made functional
• Additional contractual ANMs
• Untied funds
• Community link worker
• Village Health Nutrition committees
• Expanded Medicines supply
• PHCs made 24 x7
• Three staff nurses
• Annual maintenance grant
• Untied funds
• AYUSH Integration
• Rogi Kalyan Samiti

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The Strategies

• Infrastructure upgradation
• CHCs upgradation
• First Referral Units
• Facility survey
• IPHS
• Untied funds
• Rogi Kalyan Samiti
• District Hospital upgradation
• Facility survey
• IPHS
• Rogi Kalyan Samiti

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The Strategies

• Manpower augmentation
• Filling up vacant posts/Creating more posts
• Contractual positions to fill gaps
• Trainings / expanding training capacity
• Rational transfer and posting policy
• Health sector planning
• Household surveys Village Health Plans.
• Integrated District Health Action Plans.
• Annual PIPs / Perspective Plans.
• SPMUs/ DPMUs/ Block PMUs
• NHSRC/ SHSRC

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The Strategies

• Improved service delivery
• Citizens charter
• Monthly Health Nutrition Day
• Outsourcing critical service gaps
• Catch up rounds of Immunisation
• Improved IP OP utilisation
• Mobility Support / Mobile Medical Units
• Maternity Benefit Schemes
• Systemic improvements
• Improved logistics.
• Rational / Optimal positioning of manpower
• Rational delegation (financial Administrative)
• Decentralised procurement

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The Strategies

• Monitoring Evaluation
• Review meetings
• State visits evaluation teams, RDs
• Integrated MIS
• External Surveys
• Immunisation - UNICEF
• ASHA JSY UNICEF, UNFPA, GTZ
• Financial protocols- Institute of Public Auditors
• External Evaluations
• Community monitoring
• Encouraging State Innovations

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• Technabling
• the NRHM

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e Health

• Advantages of telemedicine in rural areas Allows
  a referral chain
• Links the patients to urban standard services
  without delinking urban service providers from
  their mileu (CME can also continue
  simultaneously)
• Easier, cost effective consultation,
  prescription mechanism
• Disease surveillance and response at various
  levels.Limitations
• high initial cost , Licensing terms and
  conditions ,bilateral Interconnection
  agreements, Non-Existence of Regulations
  Security, Legal Trade Issues
• Also
• intersectoral convergence in health sector,
  sustainability, impersonal

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Background

• India crucible for creating/testing/refining
  eHealth models.
• Ideal setting for telemedicine assisted health
  care.
• Strong fiber backbone and indigenous satellite
  communication technology with large trained
  manpower.
• Several pilot projects with successful outcome.
• Ground work on telemedicine already laid
• partnerships with ISRO, DIT, States specialty
  Institutes/hospitals.
• Policy standardization and infrastructural issues
  researched.
• Active Professional societies on e health.
• Print and electronic media participating in
  awareness

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Lessons Learnt

• Sub optimal IT infrastructure in Health sector
• Vague in principle support for eHealth.
• Poor acceptability of telemedicine by
  stakeholders.
• Administrative and financial constraints.
• Cost of equipments skilled manpower still very
  high.
• Domain skills often prevent learning of
  collateral skills.

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• National Rural
• Telemedicine
• Network

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• Design, development and implementation of low
  cost rural TM infrastructure
• consisting of fixed, mobile and hand-held
  platforms and web technology based broad band
  wired / wireless wide area network centering
  around the district hospital acting as hub.
• Design and development of Village Tele-ambulance
  System and rural emergency healthcare services /
  Trauma care module.
• through mobile telemedicine network based on
  Wi-MAX wireless mesh network
• Development of Rural Health Knowledge Resource
• through web portal on public health domain and
  creation of e-CME module for its access by the
  stake holders through e-learning technology on
  the telemedicine platform
• Development of technology for data harvest,
  compilation storage
• at regional district hub and central Data Center
  at MOH FW, archive and distribution across
  network.

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Structure of NRTN  LEVEL-1 PHC / CHC connected
to a District Hospital LEVEL-2 DH connected to a
State / National Specialty Hospital LEVEL-3 State
/ National Specialty Hospitals inter
connected LEVEL-M Mobile Unit connected to PHC /
CHC /DH  
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 LEVEL-1 Primary Health Center (PHC) / Community
Health Center (CHC) / Village Unit   Tele-consulta
tion room Patient engagement facilities (bed,
scopes, etc.) Telemedicine Platform Selective
medical and medico-IT equipments, preferably IT
compatible, with interface to Telemedicine and/or
other software / hardware Computer hardware /
software platform (PC, switch, etc.) and IT
electronics equipments Connectivity / bandwidth
requirements (e.g. ISDN, Leased line, VSAT,
Broadband, Wireless) Point-to-Point
video-conferencing system (may be portable)  
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LEVEL-2 District Hospital   Telemedicine
room Patient engagement facilities (bed, scopes,
etc.) Telemedicine Platform medical and
medico-IT equipments Computer hardware / software
platform Connectivity / bandwidth requirements
ISDN, Leased line, VSAT, Broad band,
Wireless Multi-point video conferencing
system    
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LEVEL-3 State Hospital / National Super Specialty
Hospital   Level 2 hardware/software Optional
secure centralized long-term electronic record
storage for assigned LEVEL-1, LEVEL-2, and
LEVEL-M units Connectivity / bandwidth
requirements (e.g. ISDN, Leased line, VSAT,
Broadband, Wireless)  
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LEVEL-M Mobile Telemedicine Unit  Automobile
Vehicle Chasis Size 5.779 X 2.188 X 1.900
mts Customized fabrication to accommodate IT and
medical equipments Integrated DG set, Space for
tele-consultation, patient examination Space for
carrying out investigation procedures
Ultra-sonography X-ray Telemedicine
Platform Selective medical and medico-IT
equipments, preferably IT compatible, with
interface to Telemedicine and/or other IT
software / hardware Computer hardware / software
platform (PC, server, switch, etc.) and IT
electronics equipments Connectivity / bandwidth
requirements May be customized for deployment
Boat (for application on back water in Kerala
or in Brahmaputra in Assam) Chhakras (used in
Gujarat), Camel Carts (in deserts of
Rajasthan) Application specific mobile units can
be configured Tele-ophthalmology,Tele-Cancer
care, Trauma Network and Rural Emergency system,
Suitcase-based module for Disaster-hit area, etc.
Mobile hand held units for harvesting at the
grass-root level
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• conclusion

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• Weigh the needs - emode intelligently
• Tech adoption be a function of need not fashion,
  whim or vendor pressure
• Design eHealth policies which are scalable,
  possible to implement, have a large enough
  footprint on epidemiology, address pressing
  concerns, have reasonable gestation period and
  address the entire spectrum of programme
  management.
• Develop models for intelligent logistics,
  procurement, Equipment Infrastructure
  maintenance, Pharmacy stores, HR management
  ,Training, accounting, collateral health
  determinants et al in Public Sector.
• eHealth needs tech literate planners, planners
  need plan literate scientists. Both need
  implementable, low cost technologies.
• Financing, phasing, scaling, project cycles,
  changing politics
• Governance issues and reactive nature of
  governance can delay adoption of a long term
  script for e enabled health delivery.

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ehealth - Clear the road

• Accept
• Large Capital, Per unit manpower Training
  Costs.
• Difficult to retain skilled workers.
• Outsourcing is difficult.
• Ownership of initiatives-respective Division,
  state or institutions.
• Management structure to be created.
• Capacities for content creation to be
  established.
• Detailed costing needs to be undertaken.
• Budget lines, schedules, phasing of initiatives.
• Embed budget lines in respective programmes.

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http//nrhm-mis.nic.in
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Space technology allows us to see our planet
like an emperor connect to it like a mother and
plan for it like a gold smith
With great power comes great responsibility
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• thank you
• email healthmission_at_nic.in