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ASCI – CIPS & Government of Goa Workshop on INNOVATIONS IN education & health Innovations in Health Systems – AP Experience GOA 18 November 2011

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Title: ASCI – CIPS & Government of Goa Workshop on INNOVATIONS IN education & health Innovations in Health Systems – AP Experience GOA 18 November 2011


1
ASCI CIPS Government of Goa Workshop on
INNOVATIONS IN education health Innovations
in Health Systems AP Experience GOA 18
November 2011
PV Ramesh
2
Health Innovation
Love and Health for All ......Macbeth "The
world is but a canvas to our imaginations." ..
..Henry David Thoreau
3
The presentation will cover
3
  • India Health Sector Key Issues
  • Andhra Pradesh Health Key Issues
  • Key Challenges Innovations
  • Agenda for the future

4
India Health Goals Objectives
4
  • Aim Improved access to quality healthcare,
    particularly women, children, and the poor, by
    promoting integration, decentralization, and
    encouraging community participation.
  • Goals by 31 March 2012
  • Reduce Infant Mortality Rate (IMR) to 28/ 1,000
    live births
  • Reduce Maternal Mortality Ratio (MMR) to 100 /
    1,00,000 live births
  • Reduce Total Fertility Rate (TFR) to 2.1
  • Reduce malnutrition among children of 03 years
    to half its present level
  • Reduce anaemia among women and girls by 50 per
    cent
  • Raising the sex ratio for the age group of 06
    years to 935 by 201112 and 950 by 201617
  • Provide clean drinking water to all by 2009 and
    ensuring no slip-backs

5
India Health Care Some facts
5
  • Health Care costs constitute about 5 GDP (1.1
    public / 3.9 individual financed)
  • 27 health care costs public financed (Rs 675)
    73 out-of-pocket (Rs 1,825) in AP 21 79
  • Health Care costs are growing _at_ 15 annum
  • Expenditure on Health as proportion of Public
    Expenditure - lt 3.2
  • Public Providers (25 outpatient 50 inpatient)
    Private Providers (40 outpatient 50
    inpatient)
  • Informal Providers 35 outpatient

6
Health Key Challenges
6
  • Sub-optimal health outcomes given level of income
    growth (GDP per capita)
  • Significant inter-state, regional, social, gender
    disparities
  • High financial burden on poor and vulnerable
    (40 remain poor or lapse into poverty every year
    due to illness)
  • Sub-optimal spending by public sector
  • Inadequate accountability of both public
    Private health service delivery
  • Unregulated private supply unmonitored and
    unknown quality concentration in urban areas
  • Double Jeopardy increasing burden of
    non-communicable diseases, while communicable
    disease burden remains high

7
Andhra Pradesh
  • 3th Largest State by Area
  • 5th most Populous State
  • (84 million)
  • 3rd biggest GSDP
  • Geographic, social, gender diversity

8
AP The Development Context
  • 7 of Nations Population, 13 of GDP 3rd
    Largest GSDP
  • Fastest growing State in South India
  • Health Care costs 5 GSDP
  • 21 govt. financed 79 out-of pocket
  • Government financing of Health Sector at Rs 6,170
    Cr (5,040 (state) 1,130 (NRHM) is about 1.2
    GSDP
  • Current year allocation for health sector is 4
    of total budgetary outlay
  • Has a vibrant private health sector extensive
    public health network
  • Produces 15 of health human resources in India
  • Highest IMR and MMR amongst 4 Southern States
  • Double Jeopardy Communicable NCD Mix
  • 52 of Women 43 of Children Malnourished

9
AP-DEMOGRAPHIC PROFILE

10
Maternal and Child Health
11
Infant Mortality Rate (SRS 2009)
Andhra Pradesh ranks 26 out of 35 states and UTs
in India
12
  • AP HEALTH
  • Key Challenges

13
Speak of me as I am nothing
extenuate Othello
14
Key Challenges..1
  • Health Outcomes Not commensurate with Economic
    Growth
  • IMR / MMR / Malnutrition Highest in South India
  • Communicable Disease Burden Remains High
    Increasing Prevalence of Non-Communicable
    Preventable Diseases
  • Inadequate Resources for Health Sector
  • Only 21 of health care costs financed by the
    Govt (88 UK 48 USA 51 South Africa 35
    Bangladesh)
  • 79 health care costs are out-of-pocket (Highest)
  • Only 1 GSDP and 4 Budgetary outlay is earmarked
    for health sector by the Govt
  • lt38 of total health sector expenditure is on
    Primary Health

15
Key Challenges..2
  • Iniquitous Access to Health Services
  • Geographic and Social disparities
  • Remoteness, Distance, lack of Transport
    infrastructure
  • Urban Orientation of Health Services
  • Non availability of doctors / health staff where
    required
  • Lack of Mobility for field Staff

16
Key Challenges3
  • Structural Issues
  • Institutional Architecture - Source of
    Inefficiency
  • Inadequate Integration of different Health
    Programmes
  • Lack of integrated strategy Programme of
    Action
  • Set in Reaction Mode Crisis Management Frame
  • Absent Referral System
  • Organizational Ethos Accountability
    Responsibility Missing
  • No system for Supportive Guidance and
    Facilitation
  • Inadequate community participation
  • Inappropriate / Inadequate IEC-BCC strategy
  • Inadequate integration with ICDS / SERP / RWS /
    etc

17
Key Challenges4
  • Fragmented Functional Responsibilities
  • Poor Coordination at all operational levels
  • No Public Health Cadre
  • 30-40 vacancies in critical cadres Mis-match
    posting
  • No differentiation between specialists and MBBS
  • Inadequate number of Nurses / Para-Medical Staff
  • No Health Planners / Economists / MIS etc
  • No Performance Management System
  • Inadequate capacities, especially in RCH and
    Primary Health Management

18
Key Challenges5
  • Hospital Services
  • Referral System Absent
  • Placement of Specialists Irrational
  • Nursing / Para-Medical Staff Inadequate
  • Equipment Management System Non-existent
  • Supply of Medicines and Consumables
    Inconsistent
  • Sanitation overall environment Abysmal
  • Responsiveness Quality of Care Uneven
  • Care for advanced tertiary ailments Not
    available

19
What explains the sub-optimal performance
  • Failure of the policy makers to recognize the
    importance of Health as essential component of
    Human Development
  • Lack of Political Policy Commitment in the
    absence of public demand for universal quality
    health care
  • Lack of integration of policies / programmes that
    have a direct impact on health outcomes like
    drinking water, sanitation, environment, food
    security, rural development, etc.
  • Low investment, poor policies, inadequate focus
    on quality implementation of public health
    programmes,
  • Unregulated private sector with sub-optimal
    ethical standards and quality parameters
    contributing to fuelling health care costs
  • Lack of civil society participation and community
    awareness
  • Inadequate Capacity for Effective Implementation

20
which way to go.
20
  • Would you tell me, please, which way to go from
    here?
  • That depends a good deal on where you want to go
  • I dont much care, where?
  • Then, it does not matter which way you go!!!

21
AP Health Goals
  • Provision of accessible, equitable, responsive,
    accountable, quality health services to all
    Citizens
  • Reduce financial burden of health care on
    individuals and protect BPL families from adverse
    financial consequences of catastrophic ailments
  • Empower communities and individuals to take care
    of their health and hold the health-care system
    accountable

22
Key Innovations Implemented..
22
  • Structural Reform for Health Systems
    Strengthening
  • Revitalized Primary Health System
  • Strengthened Referral System
  • Janani Mission
  • Population Stabilization
  • Systems Innovation and Process Rationalization
  • Emergency Medical Management System
  • Arogya Sri Community Health Insurance
  • Public-Private Partnerships

23
  • Innovation 1
  • Structural Reform for Accessible, Responsive,
    Accountable Quality Health Care for All

24
Structural Reform
24
  • Aligned the structure functions of Health
    Department with the goals and objectives
  • Developed and implemented comprehensive
    integrated strategy and action plan with all
    stakeholder participation
  • Rationalized the health facility location to
    improve access, fortified with infrastructure,
    human resources, capacity development, etc., for
    quality service
  • Workforce adequacy ensured along with well
    defined Job descriptions decentralized
    supervision and monitoring sustained capacity
    development

25
Structural Reform ..contd..
25
  • Differential and customized strategy, action
    plan and institutional architecture for the
    tribal and vulnerable groups, remote and interior
    areas
  • Customized strategy for prevention, control and
    management of communicable non-communicable
    diseases
  • Integrated programmes with Rural and Women
    Development departments
  • Customized IEC-BCC for community mobilization

26
Structural Reformcontd..
  • Health Medical and Family Welfare integrated at
    the Ministerial, Secretarial and HoD levels
  • Commissionerate of Health and Family Welfare
    Established
  • NRHM Mission Directorate Established
  • Directorate of Public Health Institutionalized
    Directorate of Family Health HR Proposed
  • Roles of Regional Director Technical
    supervision Programme Facilitation defined
  • Strengthened role and capacity of DMHO
  • Focus on Primary Health System Reinforced 360
    Community Health and Nutrition Clusters (CHNCs)
    Established

27
Workforce adequacy Capacity
  • 2,423 doctors 4.096 Staff Nurses Recruited
  • 451 Specialists relocated from PHCs and placed in
    CHC / Area and District Hospitals
  • 3,500 Para medical staff relocated from multiple
    PHCs and placed in CHNCs without any disturbance
  • All Para-Medical staff Posts in tribal areas
    filled
  • Leadership Training for DHMOs / DCHS organized
  • Diploma in Public Health Training for 50 Dy.
    Civil Surgeons Public Health Cadre
  • Diploma in Bio-statistics Data Management
    training for 25 Assistant Statistical Officers
    for effective data management

28
Comprehensive HR Policy
  • Well Defined Career Progress for all Cadres
  • Two years of Internship for MBBS students, of
    which one year in a PHC introduced
  • All post-graduates to work for the government for
    two years
  • Incentives for Tribal, Rural and Remote Areas
  • Revised Performance Appraisal System
  • Postings Transfers based on Merit cum Seniority
  • Establishment of HR Directorate in the anvil
  • Comprehensive Transfer/Posting, Promotion and
    Incentive policy
  • Training and Capacity Building Policy

29
Enhanced Accountability
  • Robust grievance redressal system at health
    facilities
  • Biometric Attendance Piloted
  • Institutional and Individual KPIs Introduced and
    internalized
  • Enhanced Community Participation in Performance
    Monitoring

30
  • Innovation 2
  • Revitalization of Primary Health System

31
Revitalized Primary Health System
31
  • Established 360 Community Health Nutrition
    Clusters (CHNC) Structural Functional
    Reorganization Effective MIS
  • Revitalized the Primary Health System PHC,
    Sub-Centre, Village
  • Fixed Day Village Health and Nutrition Days and
    PHC Outreach Services
  • Disease Control and RCH Program Revitalization
  • Community Participation Demand Generation
    organized
  • Customized strategies interventions for tribal
    areas and vulnerable groups
  • Targeted Interventions for adolescent girls,
    disabled, school children, elderly, etc.
  • Management Systems Strengthening
  • Performance based financing for the staff and
    target beneficiaries

32
Community Health and Nutrition Clusters (CHNC)
  • Rural AP Delineated into 360 Community Health and
    Nutrition Clusters (CHNC)
  • Each CHNC with well-defined area responsibility
    for strengthening Primary Health Care Referral
    Services
  • CHNC responsible for monitoring primary health
    activities in 5to 8 PHCs and their linkage to a
    referral centre, i.e., a CHC / Area Hospital,
    etc.
  • All CHNC referral hospital are being equipped
    with the services of atleast one MCH Team
    Anesthetist, Gynecologist, and Pediatrician
  • Each CHNC headed by a Senior Public Health
    Officer (SPHO) supported by a public health
    nurse, community health officer, sub-unit
    officer (Malaria), Leprosy Officer, Ophthalmic
    Associate, MIS Associate, etc.

33
Community Health and Nutrition Clusters (CHNC)
  • CHNC provided with mobility for well-defined
    pre-determined schedule of movement for
    supportive supervision, capacity development,
    monitoring, mentoring, etc.
  • Strengthening the Referral System Linkage
    Village ? Sub-Center ? PHC? CHC / Area Hospital
  • Effective Support and Monitoring System at the
    CHNC
  • Fixed-day Health System integrated with the
    Community Health Cluster System

34
Pre-Reform Scenario

AREA HOSPITAL or DISTRICT HOSPITAL
SC
SC
SC
Dispensary
PHC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
Community health centre No supervision over PHCs.
PHC
SC
PHC
SC
SC
SC
SC
SC
SC
SC
Mobile unit
SC
SC
SC
SC
PHC
SC
PHC
SC
SC
SC
SC
SC
SC
SC
SC
SC
35
Current CHNC System
CHC / AH / DH
SC
SC
SC
Dispensary Converted to PHC
PHC
SC
SC
SC
SC
SC
SC
SC
SC
SC
SC
Community health centre in CHNC with supervision
on PHCs
PHC
SC
PHC
SC
SC
SC
SC
SC
SC
SC
Mobile unit converted to PHC
SC
SC
SC
SC
PHC
SC
PHC
SC
SC
SC
SC
SC
SC
SC
SC
SC
36
Revitalized PHC System
  • Rationalized primary health institutional
    architecture Assorted health institutions
    converted as PHCs (dispensaries, mobile health
    units, civil hospitals, subsidiary PHCs, upgraded
    PHCs etc.
  • Service Area of all PHCs, Sub-centres
    rationalized
  • All 1,624 PHCs are being provided with
  • Two medical officers one mobile and one
    stationary every day
  • Three staff Nurses plus a one Mid-wife
  • Integrated laboratory services
  • Infrastructure for conducting normal deliveries
  • New-born care corners
  • Clear delineation of geographical and functional
    responsibility for the PHC staff
  • Mobile PHC Fixed-day Health Services
    outreach services in all villages on a fixed day
    of the month.
  • Capacity development of the PHC staff in
    comprehensive primary health services
  • Effective MIS system

37
Revitalized Sub-Centre System
  • Rationalized Service Area for each Sub-Centres
  • staffing based on the need
  • All Vacant Posts of ANMs filled
  • Service Area divided equally between two ANMs
  • One ANM trained as Mid-Wife
  • Skilled Birth Attendant Services Strengthened in
    Tribal Remote areas of the State
  • Sub-centre as the essential link between
    community and PHC
  • Coordinated action with AP-SERP and ICDS
  • Fixed-Day Village Health and Nutrition Days
  • Fixed-Day Village Health Services by Mobile PHC
  • Monthly VO PHC Meetings for Maternal and Child
    Health and Nutrition Monitoring
  • Supportive Supervision and Facilitatory Guidance
    System Established

38
Revitalized Village Level Health-Nutrition
Economic Development Linkage
  • Village Mother Child Health Teams (MCH Teams)
    with ASHA and Anganwadi Worker, SHG Health
    Resource Person lead by ANM constituted in all
    villages
  • Fixed-Day Schedule for Village Health and
    Nutrition Day and PHC Mobile Day
  • Service Area of ASHA Rationalized to ensure
    coverage of SC / ST Habitations
  • Incentive Regime for ASHA Restructured
    Performance-linked Incentives for ASHA and
    Pregnant Mothers (RBF in Action)
  • Community Monitoring of Mother and Child Health,
    Disease Prevention and Health Promotion
    Activities
  • Village Health Sanitation Committees
    restructured
  • Comprehensive Mother and Child Health Record
    Universally adopted

39
  • Innovation 3
  • Strengthened Referral System

40
Strengthened Referral System
40
  • Strengthened first and secondary referral
    hospitals with infrastructure, human resources,
    equipment, etc
  • Established CHNOs linking the primary with the
    secondary and tertiary care facilities
  • Monthly monitoring of 15 lakh pregnant mothers,
    15 lakh infants, and all children below 5 years
    with malnutrition all school children with by
    Name and referral of those requiring specialist
    attention
  • Name-based tracking of persons in the rural areas
    with chronic diseases communicable and
    non-communicable (initiated) and their referral
  • Priority for referral Cases in all Government
    Hospitals
  • Emergency Transport System

41
Strengthened Hospital System
41
  • Health Facility Survey HR, infrastructure,
    equipment, services, etc. and gradation of all
    secondary and tertiary hospitals
  • Rational Placement of Specialists Nurses and
    Technical training
  • Rational and effective management of equipment
    medicines
  • Strengthening of comprehensive obstetric and
    neonatal care services with an outlay of Rs 150
    crores
  • Special project with an outlay of Rs 750 crores
    for strengthening teaching hospitals
  • Comprehensive Sanitation Improvement Programme
  • Matrix of services provided by all hospitals
    notified for appropriate referral

42
  • Innovation 4
  • Janani MCH Mission

43
Maternal Mortality Ratio
44
Infant Mortality Rate
45
Neonatal Mortality - Share of Neonatal Deaths
to Infant Deaths (SRS 2008)
72.7
64.6
29.9
46
AP Child Mortality SC / ST Others (2006)
NFHS 3 2005-2006
Deaths 10 year period prior to date of survey
47
Janani Mission
47
  • Reduce IMR to less than 30/1000 live births MMR
    to less than 100/100,000 for EVERY VILLAGE / PHC
    / CHNC / District in AP by 2012
  • Track every pregnancy and every child until 5th
    year of age - Reduce Maternal Infant Morbidity
  • 100 Ante-natal Post-natal CARE
  • 100 Institutional / SBA Deliveries
  • Reduce Malnutrition Anaemia amongst children
    and women by 1/3rd
  • 100 Immunization of all children below 5 yrs
  • Stabilize TFR at 1.8 - Sustain sterilization /
    promote spacing

48
Janani Core Activities
48
  • MCH Teams established from the village to
    tertiary hospitals
  • Integration of ICDS SHG / VO in VHND
  • Fixed day Health services through mobile PHC
  • Name based tracking with help of Comprehensive
    MCH-Record
  • Strengthened Referral services
  • Strengthened FRU with women friendly Labour rooms
  • Established Facility based New born care centre
  • MDR IDR
  • Nutrition rehabilitation centres
  • Special plan for tribal and high focus districts

49
MCH Activities.
  • Five Centres of Excellence in Mother and Child
    Health Care under construction with an investment
    of 11 million
  • Construction of 500 Sub-centres, 114 Primary
    Health Centres and 100 CHNC Offices under
    construction- 20 million
  • 20-bed Sick New Born Care Units (SNCUs) in 17
    district hospitals and 11 teaching hospitals 5
    Nutrition Rehabilitation Centres (20 beds) in
    five Teaching Hospitals under construction at a
    cost of 11 million
  • Comprehensive Obstetric and Neonatal Care Centres
    in all 117 Area Hospitals and 17 District
    Hospitals.

50
  • Innovation 5
  • Population Stabilization

51
Total Fertility Rate
52
Population Stabilization Demographic Dividend
  • Comprehensive Population Policy Published
  • Comprehensive action plan to improve Gender Ratio
  • Safe Abortion Services in 260 / 360 Public
    Hospitals
  • Integrated plan of action to prevent, control,
    manage STI / RTI and HIV / AIDS by mainstreaming
    these activities at all levels of health care
  • Jawahar Bala Arogya Raksha
  • Adolescent Health

53
Jawahar Bala Arogya Raksha
  • JBAR launched on Nov 14th 2010 158,000 medical
    staff and teachers trained
  • 84.5 lakh children studying in 78,702 public
    schools screened for health and nutrition
    ailments
  • Issued comprehensive Student Health and Education
    Record, which is also Birth and Immunization
    Certificate
  • 181,583 children referred to secondary and
    tertiary facilities for investigation and
    treatment
  • 84.5 lakh students and 301,212 teachers
    celebrated health and sanitation day on 27
    January 2011 Health Education, Hand-washing and
    Deworming Done
  • Home visits by health staff of children dropping
    out of schools for health related reasons
  • Live-Skill Education incorporated as integral
    part of science teaching

54
  • Innovation 6
  • Rajiv Arogya Sri Community Health Assurance

55
Arogya Sri
55
  • Financial protection to BPL families for
    advanced tertiary ailments requiring
    hospitalization
  • Covers 1.97 crore BPL families having white
    ration card
  • Covers 938 surgical and therapeutic interventions
  • Coverage
  • Rs.150,000 per family per year subject to limits
  • Additional Rs. 50,000/- in case of need from
    buffer amount
  • Cashless Service for the Citizen
  • Services provided by 372 network hospitals, both
    public and private
  • Annual Allocation is around Rs 1,350 to 1,425
    crores.

56
Arogya Sri Key Features
56
  • Strong political support and public popularity
  • High-degree of patient satisfaction
  • Poor and near-poor reached, with very few
    exclusion errors
  • Improved access and emerging evidence of reduced
    financial burden for ailments covered under the
    schemes
  • Expanded partnership between private and public
    sector evidence of private sector expansion
  • Extensive engagement with the private sector in
    the areas of insurance, administration and
    provision
  • choice of providers separation of purchasing
    from financing outputs linked to financing
    Impressive use of IT / effective MIS

57
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58
  • Innovation 7
  • Emergency Medical Management System

59
Emergency Medical Management System
59
  • Emergency Medical Transport Service (EMTS) in
    partnership with EMRI
  • 24X7 emergency service for medical, police and
    fire emergencies through 108 call service
  • Emergency Transport, First aid, stabilization at
    identified Health facility
  • 752 ambulances providing cost-free transport
    service to 5,000 emergencies every day
  • Trauma care services strengthened in 27 Govt
    tertiary hospitals
  • Survey to map the emergency services available in
    all public and private hospitals under progress
  • Emergency Medical Management System (EMMS) under
    implementation

60
  • Innovation 8
  • Systems Innovation
  • Process Rationalization

61
Systems Innovation and Process Rationalization
61
  • AP Medical Services and Infrastructure
    Development Corporation (APMSIDC) Central
    Entity for Procurement and distribution of
    Medicines and Equipment Health Infrastructure
    Development
  • Comprehensive and Rational Procurement Policy for
    Medicines and Equipment
  • Essential Medicines List Published
  • Policy for use of only Generic Medicines in Govt
    Hospitals
  • Workshops and Seminars for Rational Use of
    Medicines
  • Medicines Equipment Management Information
    System

62
Equipment Procurement Policy
  • Covers full lifecycle of equipment
  • Essential Equipment List
  • For all health institutions
  • ABCD classification of equipment
  • Guidelines for Need Assessment
  • Patient load Specialist Technician
  • Rationalization of Powers
  • For Indenting, Administrative Sanction,
    Procurement
  • Streamlining Procurement procedures terms
  • Core Technical Committee
  • Systematic arrangements for maintenance _at_
    district level

Need Assessment
Indenting
Replacement
Maintenance
Procurement
Inventory Mgt
Utilization Mgt
63
  • Innovation 9
  • Public Private Partnership

64
Public Private Partnership
64
  • Emergency Medical Transport Service - 108
    services
  • Health Help Line 104 toll-free service
  • Rajiv Aarogya Sri Community Health Insurance
  • Management of PHC by NGOs
  • Advanced Diagnostic Services and Dialysis

65
  • Innovation 10
  • Health Management Information System (HMIS)
    Initiated

66
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67
  • Policy Innovations Required

68
Key Policy Interventions Required
  • Increase public expenditure on health care from
    the current 1 of GDP to 3 by 2015
  • Public expenditure on health should be increased
    from the current 3.8 to 8 by 2015
  • Increase public investment in health care to meet
    not less than 40 of health care costs by 2015
  • Reduce out-of-pocket expenses by strengthening
    the government health system and strategic
    partnership with private sector that confirms to
    quality standards
  • Resource allocation to districts and sub-district
    hospitals and health centres be based on formula
    that reckons remoteness, absence of private
    health care system, of ST / SC population,
    prevalence of diseases, etc.

69
Key Policies ..cont
  • Integration of primary, secondary and tertiary
    health systems in order to provide comprehensive
    care
  • Clear delineation of package of services offered
    by each health facility starting from the
    Sub-centre to the Teaching Hospital
  • Strengthened referral services and
    well-integrated referral system with a clearly
    defined gate-keeping system
  • Revitalization of the Primary Health System
    which is intricately linked with the first and
    second referral units with effective emergency
    transport services (108)
  • Energized comprehensive Maternal and Child Health
    Services
  • Establish independent state medical regulatory
    board along the lines of telecom regulatory
    authority to enforce quality standards on both
    private and public health system
  • Proactive Community Participation in promotive
    and preventive health

70
  • Health Systems Innovations Key Elements

71
Key Elements
  • Mandates comprehensive and integrated strategy,
    appropriate policy framework and action plan that
    are contextually customized
  • Innovation has to be based on evidence and
    empirically demonstrated
  • Strong and sustained political support enabling
    policy framework
  • Visionary and dynamic leadership, champions at
    all operational levels, a nodal strategic
    planning and innovation unit (SPIU)
  • Shared ownership of the process and the product
    by all stakeholders
  • Sustained and effective communication of the
    vision and the process
  • Absolute Transparency in all transactions
  • Credibility of the leadership and trust in
    actions
  • Special attention to losers vested interests
  • Public Participation through constant
    communication

72
Key Elements..contd..
  • Innovation is context-specific and dynamic and
    therefore has to be seen and undertaken as a
    continuous process
  • Innovation should contribute to leap in
    efficiency, improved quality and
    const-effectiveness
  • Tactical retreat is as important, if not more,
    than strategic advance
  • Be prepared for disappointment, setback, failure,
    criticism, retribution

73
THANK YOU
73
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