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Decentralised planning; implementation and monitoring of health care in India

Opportunities and challenges Indian constitutionThe state shall regard raising the level of nutrition and improvement in public health among its primary duties.There are massive interstate differences in the availability, awareness, access to and utilisationof health and nutrition care and consequently health and nutritional status of the population Health and nutrition are state subjects; state could plan & implement appropriateprogrammesfor improvement Role of the centre Evolves norms for infrastructure, manpower especially for primary health care Assists the states financially to implement public healthprogrammesthrough centrally sponsored schemes In the concurrent subject of family welfare,centreprovides funds for infrastructure, manpower, drugs, vaccines, devices and consumables for providing MCH & contraceptive care National Health Policy (1983)Health care is an essential social service Provide free health care to all in Govtinstitutions Access to health care for all by 2000 Eighth Plan Health for all with focus on reducing inter-district disparities & improving access for under privilegedsegments73rd constitutional amendmentBrought into fore the third tier of government –PanchayatirajinstitutionsHealth and nutrition are among the subjects allocated to PRI There are huge differences between states in devolution of power, funds and responsibilities to PRIRecommendations of NDC Committee on Population(1993)Decentralisedarea specific planning based on the need assessment (CNAA -RCH)Providing special assistance to poorly performing states/districts to minimisethe inter and intra-state differences in performance (Social safety net for backward districts chosen on the basis of census) Creation of state/ district level databases evaluating quality, coverage and impact of the programme(state NFHS; District level household survey)Reduction in fertility,mortality and population growth rate are major objectives of the 10thPlanThe Tenth Plan proposes to fully meet all the felt needs for FW services and enable families to achieve their reproductive goals.The families whose needs are met can and will ensure that the national goal of rapid population stabilization is achieved 10th Plan envisaged it is essential to:Undertake realistic district based decentralisedarea-specific microplanningtailored to meet the local needs.Reduce the inter and intra-state differences by replicating the strategies used by better performing districts to improve the situation Involve PanchayatiRajinstitutions inmicroplanningand monitoring at local level for effective implementation ofprogramme& ensuring community participation.Achieve incremental improvement in performance in all districts.RCH Data base at district levelIt is an enabling tool forTransformation of decentralized district-based planning for RCH programme from policy & planto actionDrawing up district action plans which are evidence-based and rationalOptimal utilisationof available inputs to implement the action planBring about intersectoralconvergence, especially between FW, health and ICDSRCH DATA BASE AT DISTRICT LEVELIt is an enabling tool For improving quality of service reportingso that service reporting provides dependable & sustainable data base for district based planning and monitoring of progress Serves as interim inbuilt evaluation of process and impact of programmeso that there is evidence based midcourse correction to improve implementation of the programmeat district levelFertility& mortality ArariaHyd’badMean No.of children Crude birth rate (CBR)Total fertility rate (TFR)Birth order 3 and aboveCrude death rate (CDR)Infant mortality rate (IMR)4.9129.14.0356.97.570.03.5114.81.5626.73.037.1Strategy to meet all the felt needs for contraception would include:In all districtsImprove access to services to ensure effective implementation Counsellingand balanced presentation of advantages and disadvantages of all available methods of contraception to enable the family to make the right choiceGood quality services in the vicinity of their residenceGood follow up care In states/districts where birth order 3 or more is > 50% of birthsEnsure ready access to tubectomy/vasectomy by sending, if necessary doctors from CHCs/District hospitals to PHC/CHC on fixed daysIn states/districts where birth order 2 or less is < 50% of the births Meet the unmet needs for spacing methods on a priority basis andalso terminal methods.Improving access to good quality sterilisationservices is priority in Araria. Why is use& unmet need for spacing method so low in Hyderabad?Current use of FPmethodsAny modern methodFemale sterilizationMale sterilizationIUDPillsCondomUnmet need for LimitingUnmet need for SpacingAraria25.522. CAREIn all districts:awareness generation so that the population ensure universal screening of pregnant women; identification of women with problem; manage/ refer to appropriate institution for care; 100% coverage for Tetanus toxoid screening for & treatment of anaemia ;provide information onnearest PHC where women with problems can seek doctor’s advice, nearest FRU with obstetricians and facilities where women with obstetric emergency can seek admission how to access emergency transport system.Antenatal careFocus in better performing districts:Improve content and quality of ANCEarly identification of women with any antenatal problemthrough universal screening by ANMs,Refer those with problems to PHC/ FRU for care.Focus in poorly performing districts:Improve awareness about need for antenatal care & danger signals in pregnancy,Improve AN screening by ANM at least 3 times in pregnancy, Build up system of RCH camps in PHC/ CHC on specific days when doctors/ specialists available to examine & treat/refer women with problems /referralANC is not done at home Araria-improve coverage under ANC ;Hyderabad-improve content & quality of ANC. It is possible to screen foranaemiabyHbestimation in the community and referanaemicwomen for treatment to PHC .Antenatal careArariaHyderNo Antenatal check-upAny Antenatal check-up3or> Antenatal checkupAntenatal at home65.834. CAREIn all districtsIdentify women with complications early, through AN check up and refer them to appropriate institution for safe delivery.In districts with low institutional deliveryscreen all women late in pregnancy; ensure that those with complications deliver in institutionstrain traditional birth attendants (TBAs) in clean delivery train TBAsto identify and refer women with problems during labourto hospitals; ensure that referrals are honoured build up community support for improvingearly rapid transport of women with problems to FRUIn districts with high institutional deliveryimprove quality of services available;address problems & needs of women in labour seeking institutional deliveries;aim at 100% institutional delivery; institutions to be people friendlymedical audit to monitor improvement in qualityof care Delivery careArariaHyd’badInstitutional deliveryIn Govthealth facilityIn private health facilitySafe delivery1.87.320.636.656.196.7Strategies for improving child healthFor all districtsAt BirthEssential new born careWeighment at birth and referral for preterm babies and neonates weighing less than 2.2 kg Nutrition InterventionsPromote exclusive breast-feeding upto 6 monthsIntroduce semi-solid supplements at 6thmonthScreen all children to identify those with severe grades of under-nutrition and treat themAdminister massive dose of vitamin A supplements as per scheduleAdminister iron-folate supplements if neededStrategies for improving child healthIn all districtsHealth InterventionsUniversal immunisationagainst the 6 vaccine-preventable diseasesEarly detection and management of ARI & diarrhoeaIn districts with high NNMRFocus on improving antenatal, intranatal and neonatal careIn districts with high IMRFocus on improving diagnosis and treatment of ARI/diarrhoeaand other infectionsArarianeed to improve coverage under every dose Hyderabad : improve timely coverage to achieve universal immunisation ImmunisationArariaHyd’badBCGDPT (Three injections)Polio (Three doses)MeaslesFull immunization45.231.831.021.519.897.084.288.377.568.5Arariaimprove access to ORS and treatment of ARI Hyderabadimprove quality of care Childhood illnesses ArariaHyd’badAware of diarrhoeaHad diarrhoeaGiven ORS to children with diarrhoeaAware of danger signs of pneumoniaSought treatment of children with pneumonia59. Five Year Plan Continued commitment to provide essential primary health care, emergency life saving services, services under the National Disease Control Programmes and the National Family Welfare Programme totally free of cost to individuals based on their needs & not on ability to payEnsure sustained funding for public health programmes Evolve, test and implement suitable strategies for levying user charges for health care services from people above poverty line, while providing free service to people below poverty line; utilisethe collected funds locally to improve quality of care.Evolve mechanism to improve quality of care at affordable cost; Evolve, implement and evaluate quality and cost of care norms in different settings Opportunities and challenges•Districts with poor indices have about 45% of the population; •they contribute to 55% of population growth , 60% of under nutrition, and mortality •Rapid reduction in fertility, morbidity and mortality in these districts are possible by improving access to simple , well tested and cost effective interventions•Centre and other states can assist in capacity building for improving access to health care. •This will enable the country achieve the goals set in NPP 2000, NHP 2002 & Tenth Plan