Decentralisation of Health Management
in
Madhya Pradesh
District Planning Process and Experiences
2004-06
Department of Health & Family Welfare
Government of Madhya Pradesh
District Health Planning
Good health has intrinsic value to enable people to realize their full
human potential. It is therefore a basic human right and a basic
developmental goal. It is the objective of development policy to make
conditions for good health available to all its citizens. The direction of
change ought to be towards decentralization. An analysis of the current
situation shows that even as the supply-side of public health care is being
strengthened, there ought to be a parallel effort at mobilizing the demand
side to demand, participate and plan for health action.
For any state decentralization process to be successful, two sets of
policies need to be developed. First, a strong leadership and strategic
conduction from the state as well as a strong support to communities and
decentralized units are needed to secure consistency of the common
efforts. Second, it is parallely required the development of a capable local
(district) government, administration and representative bodies, so
delegated responsibilities can be conducted, managed and held
accountable at that level.
Decentralization is badly needed in a large state like Madhya
Pradesh where health needs cannot be reasonably responded from the
capital. But it is also true that decentralization by itself will not solve all the
difficult problems that the health situation of the population requires.
District health plans will not bring about significant new resources which
are not available now. They will not either bring about the lacking
management skills and flexibility to improve the use of resources. The
purposes of decentralization will only be achieved through a continuous
and consistent effort and a strong commitment from the state to support
this process.
Madhya Pradesh is one of the few states in India that have realized
the potential of decentralization to radically revamp service delivery in
areas of human development and has been, since 1994, putting into place
institutional arrangements that facilitate community and intersectoral
action on key development goals.
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Madhya Pradesh Experience
Even after the coming into existence of Panchayat Raj and District
Government in Madhya Pradesh, most health programmes were vertically
managed. It goes without saying that these vertical programmes inhibit
local priorities from intervening into the management of health. The
presence of such a large number of vertical programmes is not unique to
Madhya Pradesh. A combination of donor priorities with Government of
India priorities leaves the state with no room to factor in local priorities.
To be fair to Centrally Sponsored programmes it may also have to be said
that state – level allocations are more skewed in terms of bias towards
urban areas (in comparison with CSP) which is perhaps on account of the
fact that the system extension often began from an urban locus. The
problem with all these programmes is that they carry high transaction
costs (different reporting planning, management and reporting
requirements), which fragment resources and effort. In addition they also
often by-pass the state at the planning stage, working predominantly at
Central and District level. Whilst the district will increasingly be the unit of
implementation, policy and priority setting will need to be established by
the State. This becomes increasingly difficult in such cases of extreme
fragmentation.
The GoMP established the Rajiv Gandhi Mission (RGM) for
Community Health in 2001. The RGM is situated within the Department of
Health and Family Welfare, and is monitored by the Office of the Chief
Minister through its mission status. The mission seeks to converge health
related resources and prioritize the needs of the poor in service delivery.
It plans to achieve this by strengthening and decentralizing authority to
district decision-making structures.
Decentralized Planning and Implementation is the major component
of this Mission. The core Guarantees to be achieved under the project are
Immunisation, All recommended Antenatal Checks of pregnant women,
Treatment of Common Disease and Action on Determinants of Health like
Safe Drinking Water, Sanitation, Nutrition, etc. To address all the
guarantees effectively, integrated district planning is needed. Therefore,
planning guidelines and technical manpower support were provided to the
districts for preparation of Integrated District Health Action Plans.
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The process of decentralizing planning started in February 2004
with preparation of district planning guidelines. The process also
extensively drew upon the experience of District Action Planning in Guna
district undertaken earlier in 1999 under EC-supported Sector Investment
Programme. The guidelines were finalized and approved by the state
government by June 2004. If the districts have to plan well and not merely
produce a wish list, it was also important to provide them certain
indications on the allocations available to them. One of the problems in
doing that was multiplicity of schemes as well as donor agencies. Hence
allocations under various schemes as well as that coming from donors
were estimated and then allocated to all districts according to their
population. This allocation to the districts was also communicated to them
along with the planning guidelines. The districts were also communicated
with the objectives, resources, restrictions lying with the funding
resources, indicative guidelines, common principals, etc. under various
vertical programmes/projects for better understanding.
District Planning Guidelines:
The District Planning Guidelines prepared by the department, was
just an overall framework planning process and principles. While
preparing these guidelines, the facts of district planning capacity and
district understanding of the planning exercise were kept carefully in
consideration. Special emphasis was given on the simplicity of the
guidelines.
The overall objective of the guidelines was not only to provide
planning framework but also to make districts enable to realize their
potential in the management of health care service delivery, to own the
health activities in their districts and to be responsible for the health
problem in their district as well. Intersectoral convergence is one of the
cornerstone of this process. Therefore, the guidelines had also comprised
of the rationales behind intersectoral linkage to be explored while
planning at district level. Districts were encouraged to go with the
innovative efforts to solve their health problems through the district plans.
A core group was formed in each district to facilitate this planning
process. The core group usually consisted of 4-6 persons from various
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government departments, private sector, NGOs and CBOs. The job was
entrusted to the district collectors who were supposed to be natural
leaders in terms of their key role in coordinating between various
development programs at the district level. The district collectors were
advised to take proper care in selecting persons for the core group in
such a way that those having experience in planning should only be
included in the team. A nodal officer for the purpose of coordinating the
entire exercise of planning within the core group as well as with state
technical persons was appointed from amongst the core group members.
Since the district planning exercise was taking place for the first
time in the districts especially in such a huge scope and integrated
manner, it was considered necessary to provide technical assistance to
the district. Hence a team of seven external experts and a few
departmental officials were deputed to assist the districts in the planning
exercise. One expert was assigned 5-6 districts. The experts were not
supposed to develop District Plans but only to coordinate and facilitate
the process in there respective districts along with district core teams for
formulation of the District Plan
The first step at the district level was organizing a two-day district
level workshop for identification of the problems in health sector. In this
workshop the Community leaders, PRI representatives, private sector
representatives NGOs, field level workers and representative of line
department were invited. The objective was manifold apart from problem
identification. As the participation was from almost all stakeholders, the
district level workshop in a way also served the purpose of
communicating to all stakeholders about the beginning of the process.
The experience later showed that wherever the core group was
successful in involving all stakeholders very well, the quality of district
plans was far superior to those where involvement was not very high.
Apart from problem identification, this workshop also aimed at identifying
poorly served areas named as "hot spots". This process was completed in
the months of July 2004.
After the district level workshop, the action moved on to the block
level. Every district in Madhya Pradesh is made of 3-12 smaller
administrative units called development blocks. The block medical officer
is the incharge of the primary health care in every block. A one-day
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workshop was organized in every block. The objectives of block level
workshops were to have discussions on the problems identified in the
district level workshops, identifying the possible interventions to deal with
those problems and prioritizing them. These workshops also aimed at
finding out special interventions required to deal with "hot spots", if any in
that block. Again all stakeholders were involved in these workshops
ranging from public representatives, Panchayats, private sector, NGOs to
field level functionaries of health and other related departments. The
process was completed in the month of August 2004.
The core group worked on recommendations received from these
block level workshops. As the indicative allocations were known to them,
they finalized the list of interventions based on priority assigned by block
level workshops. The final plan was placed before the District Health
Society for discussion and approval. There have been very serious
discussions and arguments in different districts over these finally
prepared plans. Some of the district also saw serious confrontation
among the members over some of the priorities. The plans were finally
approved and came to the state directorate for approval by October 2004.
As this was the first instance of district planning throughout the
state, some gaps and lack of coordination could not be avoided. As a
matter of fact, structures and strategic transformation required for
integrated planning process were in initial phase at that time. Therefore
the integrated plans prepared by November 2004 needed major
modifications. Considering the fact that refinement process would require
more time which might lead to inadequate implementation time, the
Mission decided to take a few interventions on priority
In the year 2005-06, district plans were reviewed in light of RCH II
and National Rural Health Mission. In order to ensure better coordination
at state level and compliance on NHRM recommendations, the revised
district plans were considered as Integrated District Health Action Plan
under NRHM. For the purpose of plan revision, districts were provided
specific set of guidelines prepared after consultation with other
stakeholders and as per the lessons learnt from previous year planning
exercise. Guidelines specially emphasize on district specific needs and
focused time-line of activities.
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The process for revision and further refinement of district plans
started in the month of April 2005. State and Divisional level meetings
were conducted by the Mission Office. Low performing districts or
districts with comparatively less capacities were given additional focus.
Again it was felt that the individual attention is required for each district to
ensure that the provisions made under NRHM and RCH II, are effectively
incorporated in the district plans. Hence, a team of resource persons was
identified from the department and donor partners. Each member of the
team was assigned 3-4 districts where he/she has to visit and facilitate the
planning work. After an extensive exercise of facilitation in July and
August 2005, district came up with the revised district action plans. These
plans were more logical, integrated, as per district specific need and on
principals NRHM.
Prepared District Plans had to be appraised at state level before
disbursement of funds for implementation. To effectively appraise the
district plans, it was felt that the open discussion with districts should be
held. Therefore, the district planning teams including District Collector,
Chief Medical & Health Officer Civil Surgeon, Nodal Officer were invited
with their plans at the state level. Three plan evaluation committees each
headed by a top level officer from the department (Commissioners and
Mission Director) made strenuous effort of discussing each & every
intervention with the district team.
Brief Composition of State level plan appraisal committees:
Committee 1
Committee 2
Committee 3
Chairperson
Commissioner
Health
Commissioner
cum Director
IEC Bureau
Mission Director
Members
Joint Directors and Deputy Director from the
Directorate of Health Services and resource person
for respective district.
A schedule was prepared for the appraisal process and circulated
among the districts for preparation and final discussion. Each district was
given sufficient time to present their plans, especially in context of their
district specific needs in front of a specially designed plan evaluation
committee.
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Districtwise Schedule of Plan Evaluation Discussions
Evaluation Commitee
10:00 AM
to
12:00 PM
Time
Date
All three teams together
12:30 PM
to
03:00 PM*
Satna
03:30 PM
to
05:30 PM
Hoshangabad
Shri Manoj Jhalani,
6th September 2005
Guna
Ashoknagar
Gwalior
Commissioner, Health
7th September 2005
Rajgarh
Shivpuri
Datia
9th September 2005
Vidisha
Raisen
Sehore
14th September 2005
Bhind
Shyopur
Morena
16th September 2005
Shahdol
Anooppur
Balaghat
Shri Anurag Jain,
6th September 2005
Sagar
Damoh
Chhatarpur
Commissioner,
7th September 2005
Panna
Narsinghpur
Tikamgarh
8th September 2005
Shajapur
Bhopal
Harda
9th September 2005
Sidhi
Rewa
Dindori
Shri Ashok Barnwal,
6th September 2005
Ujjain
Mission Director, NRHM
7th September 2005
Jabalpur
Khandwa
9th September 2005
Betul
Dhar
Jhabua
12th September 2005
Indore
Burhanpur
Mandla
13th September 2005
Dewas
Khargone
Badwani
14th September 2005
Mandsaur
Neemuch
Umariya
16th September 2005
Chhindwara
Ratlam
Seoni
27th September 2005
Seoni
30th September 2005
Sheopur
and other officials.
IEC Bureau
and other officials.
and other officials.
Katni
Balaghat
* Time slot 12:30 to 03:00 includes 30 Minutes working lunch time.
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This process took the complete month of September 2005. All 48
district plans were examined by the committees and districts with
innovative ideas or well-designed plan are not only being appreciated but
also quoted for their efforts to other district. Moreover, the poor
performing districts have been given special attention and focused
technical support for finalization of plans in given timeframe. Based on the
evaluation by these committees, the activities that did not have any policy
implication, were sanctioned. The activities that require policy level
relaxation or those were new schemes were listed out district wise and
districts had been asked for detailed documentation and to incorporate
necessary changes as per the discussion with appraisal committee in
their district plans.
During the evaluation process lots of innovative activities were
reflected in the District Plans. Many of them which were on the line of
State Policies and were agreeable as per the norms of Financial
resources were also approved. For the purpose of quick action on
improving Service delivery in the rural, remote and underserved areas,
activities like organizing Health Camps/Mela, village level meetings and
community mobilization efforts were also sanctioned. Some of the
sanctioned innovative activities taken under different district plans are as
follows:

Alarming Bells (manual) in the Anganwadi Centres for reminding the
mothers to take the medicine provided to them.

Protein biscuits to severely malnourished children.

Janani Express Scheme to provide transportation to the pregnant
mothers for institutional delivery.

Display board and question box in the schools for providing
counselling to adolescent school going boys and girls.
The districts have started implementing their district plans now and
the funds have been made available to the District Health Societies.
In order to provide better coordination with state and continuous
technical support to the districts, the four Area Health Managers were
placed at Regional Headquarters with instruction to visit their districts
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extensively on regular basis. The observation of the AHMs and other
officials visited the districts till October 2005 are as follows :
The micro planning of each activity under the District Plans was
completed in most of the districts and execution of activities has
been started.

The CM&HO and District Collectors, who were present in the
discussion under appraisal process, are feeling themselves
responsible for implementation in agreed time frame under their
plans. As a result of same, frequent meetings, reviews and
extensive visits of the rural areas are taking place for effective
implementation.

The District Collectors who are also the chairperson the District
Health Society and CM&HOs are now effectively working for the
implementation in well coordinated manner and also realizing their
responsibility for the local health problems.

Greater sense of Ownership among the stakeholder for health
services and activities was observed.
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