Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
Rajasthan –Health:
Scenario
Structure
Schemes
Services
Sector reforms
1
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
Background
Rajasthan:
Location:
The largest Indian State
Northwest India,
Land locked: Punjab in the north,
Haryana and Uttar Pradesh in the northeast,
Madhya Pradesh in the east and
Gujarat in the South.
Neighboring country -Pakistan
Area:
342240 sq. km
10.41% (of the total country area)
Terrain:
Desert
Plain
Hilly
Tribal:
5.85 % (of total state area)
Population
56, 473, 12 (2001)
Divisions:
07
Districts:
33
Municipalities: 183
P. Samitis :
237
Panchayats
9188
Villages :
39793
II. Demographic Profile and Key Health Indicator: India and Rajasthan
Sources:
Indicators
Rajasthan
Population (2001) in million$
56.51
Projected Population (2008) in million@
66.41
Decadal population growth rate, 1991-2001
28.41
Sex ratio (females per thousand male)
921
Per cent urban
23.39
Literacy rate total
60.4
Literacy rate male
75.70
Literacy rate female
43.9
Per cent Scheduled Cast
17.15
Per cent Scheduled Tribe
12.56
Total fertility rate *
3.2
Crude birth rate ** (CBR)
28.6
Crude death rate ** (CDR)
7.0
Infant mortality rate ** (IMR)
68
Maternal Mortality Rate**
445
Population per sub center
4557
Population per PHC
32193
Population per CHC
147394
Doctors population Ratio
1:9657#
$ Census of India 2001,
# Based on total population of 2001
* NFHS-III 2005-2006
* *SRS-2005
@ Projected population (March 2008 Census of India).
India
1028.61
114.76
21.34
933
27.8
64.8
75.3
53.7
16.2
8.2
2.7
23.8
7.6
58
301
-
2
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
Key Indicators for Rajasthan from NFHS-3 (2005-2006)
Key Indicators for Rajasthan
Women age 20-24 married by age 18 (%)
Men age 25-29 married by age 21 (%)
Total fertility rate (children per woman)
Women age 15-19 who were already mothers or pregnant at the time of the survey (%)
Median age at first birth for women age 25-49
Married women with 2 living children wanting no more children (%)
Any method (%)
Any modern method (%)
Female sterilization (%)
Male sterilization (%)
IUD (%)
Pill (%)
Condom (%)
Total unmet need (%)
For spacing (%)
For limiting (%)
Mothers who had at least 3 antenatal care visits for their last birth (%)
Mothers who consumed IFA for 90 days or more when they were pregnant with their last child (%)
Births assisted by a doctor/nurse/LHV/ANM/other health personnel (%) 1
Institutional births (%)
Mothers who received PNCcare from health personnel within 2 days of delivery for their last birth (%)
Children 12-23 months fully immunized (BCG, measles, and 3 doses each of polio/DPT) (%)
Children 12-23 months who have received BCG (%)
Children 12-23 months who have received 3 doses of polio vaccine (%)
Children 12-23 months who have received 3 doses of DPT vaccine (%)
Children 12-23 months who have received measles vaccine (%)
Children age 12-35 months who received a vitamin A dose in last 6 months (%)
Children with diarrhoea in the last 2 weeks taken to a health facility (%)
Children with acute respiratory infection or fever in the last 2 weeks taken to a health facility (%)
Children under 3 years breastfed within one hour of birth (%)
Children under 3 years who are underweight (%)
Women whose Body Mass Index is below normal (%)
Men whose Body Mass Index is below normal (%)
Women who are overweight or obese (%)
Men who are overweight or obese (%)
Children age 6-35 months who are anaemic (%)
Ever-married women age 15-49 who are anaemic (%)
Pregnant women age 15-49 who are anaemic (%)
Women who have heard of AIDS (%)
Men who have heard of AIDS (%)
Women who know that consistent condom use can reduce the chances of getting HIV/AIDS (%)
Men who know that consistent condom use can reduce the chances of getting HIV/AIDS (%)
Currently married women who usually participate in household decisions (%)
Ever-married women who have ever experienced spousal violence (%)
57.1
56.7
3.21
16.0
19.6
72.8
47.2
44.4
34.2
0.8
1.6
2.0
5.8
14.7
7.3
7.4
41.2
12.8
43.2
32.2
28.9
26.5
68.5
65.2
38.7
42.7
13.2
56.6
68.9
13.3
44.0
33.6
33.8
10.2
8.4
79.6
53.1
61.2
33.8
74.2
27.3
63.2
40.2
46.3
3
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
Health Infrastructure
Health Facilities
SN
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
State/Zone
Rajasthan
Ajmer
Bharatpur
Jaipur
Bikaner
Jodhpur
Udaipur
Kota
District
Ajmer
Tonk
Bhilwada
Nagaur
Bharatpur
S.Madhopur
Karauli
Dholpur
Jaipur
Dausa
Sikar
Jhunjhunu
Alwar
Bikaner
Churu
Hanumangarh
Sri Ganga Nagar
Jodhpur
Pali
Jalore
Sirohi
Barmer
Jaisalmer
Udaipur
Dungarpur
Banswada
Chittorgar/Partapgarh
Rajsamand
Kota
Baran
Jhalawad
Bundi
DH/SubDistrict
Hospital
126
9
3
3
5
4
3
1
1
19
1
1
3
4
7
5
2
1
13
3
2
2
3
2
9
3
2
3
2
5
1
2
2
126
Types of Facilities
CHC
PHC
349
11
7
15
17
12
4
5
6
18
7
16
13
21
9
10
8
11
14
15
8
6
14
5
19
7
12
14
7
9
9
14
6
349
1503
43
45
64
88
56
22
27
21
89
29
67
70
73
41
55
39
39
66
65
50
22
58
15
73
38
46
54
35
27
35
28
25
1503
Sub
Centers
10512
285
248
392
605
365
197
226
160
505
234
494
323
463
298
353
277
350
498
418
357
187
465
137
551
305
338
394
208
162
210
232
175
10512
The 10th Plan approach focussed on Health sector reforms in areas like efficient & effective public
health care, improved organization & Management, Effective implementation of Health programs,
Quality Medical education and Promotion of participation by private sector; wherein Strengthening
of Infrastructure, Creation of new Infrastructure and strengthening managerial capacity were the
main activities.
The Department could develop a reasonable Health care delivery infrastructure despite some
regional imbalances and a positive change was observed during the plan period in indicators like
Crude Birth Rate (28.6,NFHS-III) Crude Death Rate (7.0, SRS-2004), IMR (67, SRS-2004),MMR
4
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
(445, SRS-2004), CPR (45.8, 2006, GoR), and TFR (3.2,NFHS IIII).Further, despite a little
convergence observed particularly during 2005-06 and 2006-07; the disease specific programs
have made substantial change in the Burden of Diseases in Rajasthan.
Much still remains to be done to bring the health of State in the mainstream of National averages.
Guided by issues of Equity, Gender imbalances, Access and availability, Quality, Decentralization,
Institutional strengthening and capacity development, the State has identified its Goals in
consonance with National Health Policy, Millennium Development Goals and the basic strategy of
NRHM; taking full cognizance of the strengths and weaknesses of the system while capitalizing the
opportunities in its way.
The State in the last few years have shown progress in terms of health status and outcomes , but
the major health indicators are still below the National average .
Health Administrative Setup:
The organization structure
Principal Health
Secretary
Secretary FW and
MD NRHM
Director Public
Health
Director IEC
Director F W
Director SIHFW
Director AIDS
Additional Director- State level
Joint Director
State Level
State PMU
Divisional Level
District Level
PMO
District PMU
CMHO
Deputy/Additional
CMHO
RCHO
Block PMU
Medical Officer
5
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
Medical Education in the State
SN
Medical College
Management
Approved intake
SMS Medical College, Jaipur
SP Medical College, Bikaner
RNT Medical College, Udaipur
Dr. SN Medical College, Jodhpur
JLN Medical College, Ajmer
Govt Medical College, Kota
Mahatma Gandhi National Institute of Medical
Sciences, Jaipur
National Institute of Medical Sciences, Jaipur
Jhalwad Medical College
Govt.
Govt.
Govt.
Govt.
Govt.
Govt.
Private
150
100
100
100
100
100
100
Private
Public-Private
partnership
Govt.
Private
Private
Private
100
100
Private
Private
100
50
Private
100
Private
60
Private
100
Private
Private
50
100
Dental Wing, SMS Medical College &
Darshan Dental College & Hospital,
Jaipur Dental College & Hospital,
Pacific Dental College
Surendra Dental College & Research Institute,
Jodhpur Dental College & General Hospital,
Jodhpur.
Rajasthan Dental College & Hospital, Bagru
Khurd, Jaipur.
College of Dentistry,Mahatama Gandhi National
Institute of Medical Sciences, Jaipur.
Ekalavya Dental College & Hosp., Koputli, Jaipur
(Rajasthan)
NIMS Dental College, Jaipur
Vyas Dental College & Hospital, Jodhpur
40
100
100
100
Since the Department has already subscribed to the concept of Public Private Partnership, wherein
the private sector will be pursued to invest in capital intensive, state of art diagnostic equipments
and Medical education; the plan outlay of the Medical Education shall be substantially reduced.
In the ISM sector also, the proposed integration of ISM with official health care delivery system will
reduce the cost on account of construction and mobile ISM units, substantially, as they will be using
present and infrastructure to be created by medical and health department
The issues that punctuates the sanguinity of the present approach is a meagre number of
specialists available to man the Community Health Centres and the incompatible output of
specialists that the 9 ( one in pipe line) Government Medical schools annually churn out needs
immediate remedial measures will have to be taken up by increasing the number of Post Graduate
seats
For the first time the planning exercise takes into consideration the population, the State will have at
the end of Plan (2012), so that the manpower and institutional strength match IPHS standards and
Population based norms respectively. This obviously yet aptly inflates the budgetary requirement.
Learning from the gaps and reasons thereof, the Department of Health & Family Welfare in Govt. of
Rajasthan, has done a vigorous SWOT analysis to draft a relatively prudent & pragmatic plan for
future 5 years so as to contribute effectively to national developmental goals besides putting
Rajasthan on a relatively higher pedestal in terms of National Indicators at the end of 11 th Five Year
Plan period
6
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
Human Resources
S. No.
Title
Number
Title
Numbers
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
BDS
DA
DCH
DFM
DGO
DIHBT
DM (NEURO)
DM (ONCO)
DMRD
DNB
DPH
DPM
DTCD
ENTOMO
MBBS
MCH
MD (ANAE)
MD (FM)
MD (Med.)
MD (Micro)
MD (Paed.)
MD (Path.)
MD (PSM)
MD (PSY)
MD (Radio)
MD(REHAB)
MD (Skin)
MD (TB)
MDS
MS (ENT)
MS (Gynae.)
MS (Ortho.)
MS (Ortho)
MS (Surgery)
TA
Vacant Posts
106
17
49
14
35
9
1
1
7
1
8
2
9
1
3615
5
123
3
483
5
252
43
31
26
50
5
19
71
1
93
325
127
134
415
18
1560
Total
7664
Additional Directors
Additional Supt.
Assistant Director
Assistant Professor
Clinical Psychologist
Coordinator
Dietician
Director
Dy. CM&HO
Dy. Directors
Dy. Supt.
Entomologist
JS
JSC
Joint directors
Lecturer
Medical Officers
Medical Officers (DENT)
MOC
Neuro Surgery
PG
PH Lec.
SMO
SMO (DENT)
Senior (Demo)
Senior (LEC)
SS
STO
APO
Deputation
Extra
Higher Education
Lama
Long Leave
Others (Not Joined, Resign, Suspend
No filled
Absent
Total
8
2
2
5
8
1
1
4
52
93
1
1
1762
18
21
1
3662
105
62
1
197
1
800
13
6
1
273
1
27
39
81
1
5
1
135
176
97
7664
The guiding principles for the State Health care delivery are: Equity – Poverty Focused
 Gender Sensitive
 Access and availability
 Quality
 Convergence
 Development focused
 Decentralization
7
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008



Institutional strengthening and capacity development
Public Private partnership
Community Partnership/ Involvement
At the State level a thorough analysis of the potential and punctuations has been done
SWOT analysis (in context of National Health Policy-2002):
1.
Strengths:
a.
b.
c.
d.
e.
f.
Policy promoting Private investment
State Population Policy
Commitment
Infrastructure created under different Schemes and Projects
Planning cell in DMHS
Financial inputs (surplus in different schemes/ Projects, inappropriate
Utilization)
g. Private sector in Medical Education
h. University of Health Sciences
i. Training Policy
j. RMRS(User charges, Life line fluid stores)
k. Essential Drug List (though needs revision).
2.
Weaknesses:
a. Planning ( Ad hoc, evidence base missing, Need to develop “ Information
Culture”, resurrect & sustain area-specific Micro-planning efforts that were
once initiated in 1994-95, No strategic State plan-Planning cell functions
limited to targets and budget allocations)
b. Vertical implementation, Duplication of efforts (Donor Pressure & Priorities),
Lack of Integration
c. Implementational competence for capacity & juggling priorities
d. Training (Repetitive, content, class room based, Profile of trainees-Age, no
feed back)
(To be made Centralized at identified institution with identified core group of
minimum 10 Trainers- exclusive to the job) SIHFW to take the lead
e. HMIS (fragmented, survey based secondary data, ad hoc approach, out of
“compliance”, for print v / s in planning use of data, Technology)
f. Mobile Camp approach/ Door step delivery ( has increased dependence and
resulted in poor utilization leading to increase cost; reconsider)
g. Urban bias of Medical education & Training
h. Limited intake capacity of Medical Schools
i. Lack of accreditation system
j. No regulation for Clinical Establishments (Clinical establishment regulationAct?)
k. Urban Health care
l. Majority of Projects & Schemes, by and large, restricted to 7-8 Districts
m. Location of Health Facility (impact on utilization?)
n. Health Policy
o. HRD Policy (Managerial capability, Future projections? Job enrichment?)
8
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
3.
Opportunity:
a.
b.
c.
d.
e.
4.
NRHM (Funding & Commitment)
RSHSDP
Integration of ISM
Expression of intent by corporate Hospitals to come to State
Tele-Medicine project
Threats:
a.
b.
c.
d.
e.
Program specific Societies to implement under donor pressure
Changing Morbidity Profile
Manpower shortage (Nurses & Paramedical)
Frequent changes in position of trained manpower
Increasing cost of Drugs
(Generic prescriptions and a prudent essential drug list can help)
f. Un-utilized funds, next kitty might get reduced (Financial Planning, System
of Accountability)
g. Contract employment (v / s Service based payment system)
h. Non-existent Disaster/ Epidemic management plan
i. Wide geographical disparities
j. Non implementation of transfer policy
Objectives and Priorities:
Objectives
:To achieve levels indicated in National Health Policy-2002
Priorities
:Decide on Indicators and quantify the achievable, in context to National
Policy
Prioritize indicator(s) where change is to be sought and then identify and
dovetail all programs & activities expected to make impact besides, pooling
of finances irrespective of source, e.g.
i. Indicator
: MMR
ii. Present situation: 445 (SRS-2004)
iii. Goal (say)
: 400 by end of 11th Plan
(State Pop. policy aims at
285 by 2011)
: NRHM aims at 148 by 2012
iv. Programs/ Schemes :
a. Major-NRHM, RCH, FW
b. Minor: Immunization, ICDS
c. Support: RSHSDP
v. Identify & club activities related toInfrastructure
Logistics
Training
Service delivery
Monitoring
vi. Funding :
a. State
b. Central
c. Bilateral agencies
vii. Sub areas that will be addressed:
a. IMR
9
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
b. CPR
c. CBR
d. CDR
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
State Policy and Planning (Health & Hospital) wing with strong HMIS (Information
and Data on health related events & activities, from all levels including Medical
Colleges, to be compiled & used in monitoring & planning)
Develop discipline of Public Health/ Community Medicine (assign 1/4 of PG seats,
NHP-2002)
Health Research (allocate 2% of total Health budget, NHP-2002)
Strengthen State Epidemiology Cell and create District Epi. Units with trained
manpower, adequate infrastructure and finances.
i. Capacity building of Service providers and Managers through:
Induction Trainings by SIHFW,
Incremental planning and financing
Capacity building of LSG & PRIs
Interface between Health & Environment related programs
visible Objectives identifying indicator where change is to be made and quantum of
change
by end of 11th Plan
Medical Education
i. Increase Intake
ii. Consider NRI seats in Govt. Colleges
iii. Health University for uniformity
iv. Regulation of Standards in Para Medical courses & Training
Develop a strong referral linkage with down referral and feedback
Private Public Partnership:
Need:
1. Increasing cost of care for people as well as providers
2. Increasing awareness & expectations
3. Limited resources (only 0.9 % of GDP allocated for Health)
4. New emerging diseases,
5. Changing disease profile,
6. Technical and diagnostic advances,
7. Longevity of life(Increasing BOD),
8. Subsidies and cross-subsidies
9. Increasing non-plan expenditure, and
10. Competing priorities
11. Medical/ Health Tourism
Steps:
1. Policy (Private Investment promotion policy already pronounced)
2. Enumerate strengths of Private sector (Allopathic & ISM)
a. Geographical presence and number
b. Specialization
c. Advancements
(Seek help from Private practitioner’s society or a private agency for enumeration)
3. Work out a mechanism for spare capacity utilization (resource pooling)
4. Out-sourcing by Public Sector, particularly for capital-intensive & Technology
based interventions
5. Identify areas & Services where Private sector could be supportive
a. Low coverage areas (Empanelment as in NHS (UK) or ESI) particularly with
reference to areas where manpower shortage exist e.g. Anesthetists and
Gynecologists
b. Advance diagnostics
10
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
6.
7.
8.
9.
10.
c. Advanced interventional procedures
d. Implementation of National Health Programs (Require sensitization in context to
approach e.g. RNTCP, UIP and involvement).
e. Medical/ Dental and Para Medical training schools
Referral mechanism for Private sector on predefined terms of payment
Accreditation system for promoting Health Tourism
Develop norms & Standards for Health care facilities
Involve Private sector in planning (nomination, Circulation of Drafts for comments,
invitation to planning and Monitoring meetings)
Health Insurance (to be offered on payment or purchased on premium?)
Beneficiary Specific Programs, Policies & Program design:
Basic premise:
1. Trust (System works-Eradicated Small Pox, Guinea worm –a history, Nearing
eradication of Polio)
2. Punctuations to Achievements (hitherto and henceforth)
i. Vacancies
ii. Presence of service providers
iii. Frequent Paradigm shifts
iv. Utilization
1. Logistics
2. Availability of services & Manpower
3. Competence of providers
4. Camp approaches
5. Past experience
6. location of facility
3. Policy v/s Implementation
4. Sustainability of efforts?, for shift in priorities
5. Monitoring & Feedback
6. NRHM shall be in place till end of 11th Plan withi. Convergence
ii. Integration
iii. District centered
iv. Focus on PRIs & LSG
7. No State Health Policy
8. Presence of Private sector
9. Practitioners of ISM-supplementary not substitutes of Official System
Policy Prescription Issues (for the entire plan period):
a. Restructuring of Health Care Delivery System
b. District to be basic Planning & Executing agency
i. Area specific, evidence driven, priority based Micro planning
ii. Convergence ofa. Priorities
b. Efforts
c. Finances
iii. Strengthening of District Health System in terms of Manpower/ Logistics/
Managerial competence/ Job enrichment/Administrative & Financial powers
to improve effective implementation
iv. Training policy implementation(Duration-lower the level higher be the
period)
v. Defined job responsibilities (Document already scripted)
vi. Placement & Transfers within District
a. Seek choice
b. Place for 5 years (refer to transfer policy)
vii. District planning( Health & Hospital) cell with HMIS and automation
11
Compiled & Developed by:
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For Health Sector Reforms Workshop
June 19, 2008
viii. District Epidemiological units, with Rapid Response Teams & Laboratory(
with placement of trained manpower &logistics)
ix. Monitoring and evaluation instruments and mechanism
x. Citizen Charters
xi. Service Delivery
a. Gen. population
i. Freebees
ii. Services on Payment
b. BPL families
i. Enlistment
ii. Regulatory Mechanism to address misuse
c. State to i. Offer Basic broad guidelines in consonance to State (?) & National Health
Policy-2002
ii. Develop Norms & Standards
iii. Facilitate Fund flow from Central agencies
iv. Monitor quarterly
d. NGOs
i. Enlistment (probably already in place)
ii. Capacity & Experience ( in Health care)
iii. Explore possibility of transferring selected Primary care units
a. Norms to be followed
b. Manpower (Govt.? or by NGO)
c. Initial Support?
d. Recurring expenses- Reimbursement in part, full or none
e. Freedom to levy user charges
iv. System of Accountability
e. PRIs & LSG to own primary health care in Rural & Urban areas.
i. Approacha. Selected PHCs or all PHCs in selected districts
ii. Willingness & Competence(?) of PRIs to own & manage primary care
iii. Funding Mechanism
iv. Authority & Autonomy
v. Checks to watch misuse
vi. Delivery of care through a System mix (ISM+ Allopathic), availability under
one roof
vii. Relocation of Institutions (from outer skirts to centre of village- increases
utilization) and provision of residential units
viii. Cost recovery-User charges? (assures ownership & involvement)
ix. Community based Health Insurance (Health Care Cooperatives-Chinese
experience?)
x. Mechanism for interaction and developing linkages with Secondary/
Tertiary care
xi. Manpowera. from State pool, minimum 3 years, or
b. On contract, service based payments
12
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
Health Sector Programmes
National Rural Health Mission/ Reproductive and Child Health Phase- II
The National Rural Health Mission (2005-12) seeks to provide effective healthcare to rural
population throughout the country with special focus on 18 states, which have weak public health
indicators and/or weak infrastructure. RCH-II is a major programme that comes under the umbrella
of the NRHM .The overall goal of RCH Programme is to reduce infant and maternal morbidity and
mortality as well as total fertility rate in the state. These goals will be achieved through improvement
in quality, enhancing accessibility and availability and coverage of the reproductive and child health
services, including family welfare services. The Programme will emphasize empowerment of
women and communities for enhancing health service utilization to achieve reproductive health
goals and population stabilization.
The Programme goals are stated below:
Indicators
Total Fertility Rate
Birth Rate
Death Rate
Infant Mortality Rate
MMR
Source:* NFHS-III 2005-2006
**** Goals set as per XI Plan document
2007
3.21*
28.6**
7.0**
68.0**
445***
**SRS-2005, ***SRS- 2003,
2012****
2.1
21.0
7.0
32
148
Some of the initiatives under the NRHM/RCH-II programme
ASHA- Sahayogini: In order to increase utilization of health facilities and services, under the
National Rural Health Mission, a trained village based health worker named ASHA Sahayogini
(Accredited Social Health Activist) at every 1000 population will act as a bridge between rural
women and children and health services in the State of Rajasthan. However, for tribal and desert
districts which have many small villages with population less than 1000, this norm has been relaxed.
Till March 2008 a total of 39325 ASHA-Sahyoginis have been selected. In year 2007-2008,
selection of remaining ASHAs will be completed. The ASHA Resource Center (ARC) has been
established at State level in State Institute of Health and Family Welfare which is providing technical
backstopping to the programme. ASHA-Sahyogini Mentoring Group is constituted at State level to
provide guidance to ASHA-Sahyogini programme.
Untied Funds: To strengthen the Sub center and referral system, each sub center has been given
Rs.10000/- as untied fund and joint account of ANM and Sarpanch have been opened. Three
trenches of the Untied funds have been disbursed to the Sub centers. Untied funds have been also
disbursed to the District Hospital, Community Health Center and Primary health centers.
MCHN Days: The Mother and Child Health Nutrition Days are being organized on a particular fixed
day once in a month in all 40,000 villages for providing the services related to mother and child,
immunization and nutrition.
Jan Mangal Couple: To promote the accessibility and awareness on the non clinical contraceptives
in the villages, a Jan Mangal Couple has been provided for a population of 1000.They enhance the
community based distribution of the contraceptives.
First Referral Unit and 24 * 7 PHCS : FRU are being operationalised in the state to provide
emergency obstetric care , neonatal care and blood transfusion services . 24x7 PHCs are also
developed to provide 24 hrs services to the community.
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For Health Sector Reforms Workshop
June 19, 2008
IMNCI: Integrated Management of Neonatal and Childhood Illness (IMNCI) is implemented in all the
districts of Rajasthan. This is an integrated and effective approach for managing neonatal and
childhood illness.
Life Skills Education: In collaboration with the Education Department, the Life skills education has
been incorporated as a separate subject in the curriculum of the 11 th Class. 3.5 lakh children are
being covered under this initiative.
Malnutrition corners: To address the malnutrition among the children, malnutrition corners have
been operationalised in the District hospital to provide the complete range of services for addressing
the malnutrition.
A glance at the achievement of the RCH –II programme under the Family Planning, Maternal
Health and Child Health for the year 2007-08
S.No. Particulars
ELA
%
Achievement
%
Increase/
Decrease from
last year
73.21
16.29
99.16
114.57
119.43
98.43
11.41
8.55
6.86
3.97
982837
47.96
13.29
1337321
65.25
18.89
Achievement
12555
322474
335029
337979
635541
744866
2017195
8
Male Sterilization
Female Sterilization
457655
Total Sterilization
IUD Insertions
340827
OP Users (New)
554705
CC Users (New)
623690
ANC Registration
2049383
ANC Registration with in 12
2049383
weeks
ANC Registration who have
2049383
received 3 check-up
TT (PW)
2049383
1915998
93.49
4.19
9
Institutional Deliveries
1844445
1018842
55.24
40.97
10
11
JSY Beneficiaries
Full Immunization
1738250
774877
1615685
92.95
2.72
1
2
3
4
5
6
7
NRHM and RCH Components: Progress
SN
1
2
3
4
Activities
District Health Society Meeting
ASHA Sahyogini Selection
Untied fund Account ( Sub Centers
IPHS
Expected accomplishment
384
42136
10742
128 (CHCs)
5
6
7
8
9
10
11
12
13
14
AYUSH Integration
Dai Training
RCH Camp
Additional ANM Selection
Functional BEmOC
PHN selection
LT selection
RMRS Registration
IMNCI
RMRS Registration (PHCs)
657
6000
1920
1321
176
158
158
1907
180
1503
Achievement
236
39325
10498
Facility Survey done
;116
Civil
Work
/Training done in 85
632
2647
1682
943
130
133
135
1911
168
1503
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SIHFW
For Health Sector Reforms Workshop
June 19, 2008
Intersectoral Convergence in NRHM
To achieve the goals and objectives of NRHM ensuring the intersectoral convergence is very critical
as the achievement of health is determined by various factors. The role of the different departments
like Women and Child , Education , Panchayati Raj, PHED and AYUSH is very critical in achieving
the objectives of the RCH-II programme . Convergence in planning and other stages of
implementation of program is very important and NRHM has various institutional mechanisms like
State health society and District health society to facilitate the same. The various convergent
programmes with the different departments and the challenges are detailed below;
Convergence with DWCD
1. AWC has become the focal point of health and nutrition services. Role of ASHA has been
given to Sahyogini’s of DWCD so that greater convergence can be achieved. Integration in
training and BCC is need to be emphasized.
2. MCHN day is observed on each AWC where all the activities of health, nutrition and NRHM
being observed. Monitoring of MCHN days is an important issue. Supervisory visits of MO
in MCHN days can make the difference in the quality of services. Lack of supervisory staff
especially in Rajasthan is a big challenge to ensure the quality MCHN days.
3. Joint planning at each level, common BCC strategy at state and district level, joint training
and joint M&E are some of the areas of convergence with DWCD which can be explored.
Convergence with PRIs
1. Panchayats have been assigned 29 rural development activities, out of them several are
related to health and population stabilization. Provision of strengthening of VHSCs under
NRHM is one of the critical areas of convergence. Under NRHM provision of untied fund of
Rs.10000 to each VHSC is a step to involve the panchayats in health activity. There is a
need to sensitize the members of the VHSC about village health plan and its
implementation.
2. Preparation of village health plan and its implementation is one of the opportunity to
panchayats for taking ownership in matters of health is their area.
3. Particular emphasis & interventions for PRI relate to registration of births, marriages and
deaths enabling death audits, ensuring transport for emergencies, ensuring legal provisions
regarding age at marriage and finally ensuring that services are in consonance with needs.
4. In health sector, devolution of powers to PRIs is an issue. In some of the sectors devolution
of powers is still awaited. Transfer of funds, its judicious utilization and priority to
addressing the need of vulnerable groups is some of the issue need to be addressed in our
state.
5. The role of Panchayats in the area planning, community monitoring, supervision of services
and registration of birth , deaths should be strengthened.
Convergence with NACP
Convergence at program level in NACP is still awaited. Number of activities in NACP and RCH-II
are common. To reduce duplication in fund disbursement and supplies and drugs ,common
planning, common M&E and joint training and BCC mechanism need to be evolved. Areas of
convergence are :
1.
2.
3.
4.
5.
RTI/STI management
Condom promotion by ASHA
VCTC and PPTCT services to HRC through ASHA
BCC/Training
Mother NGO and TI-NGO Schemes
15
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For Health Sector Reforms Workshop
June 19, 2008
AYUSH Integration
An effort is being made to integrate AYUSH System in Health Care Delivery System under National
Rural Health Mission. For mainstreaming of AYUSH in NRHM, the personnel of AYUSH shall work
under one roof and separate space would be allocated exclusively for them in the same building. In
case, separate space is not available at the PHCs/CHCs civil works will be undertaken from the
funds provided to Ayush Department for this purpose. AYUSH Practitioners are appointed on
contractual basis so that AYUSH becomes a part of Primary Health Care and AYUSH medicine will
be dispensed through them.
Convergence with PHED
Swajaldhara, TSC and NRHM rely on community lead approaches. As TSC and Swajaldhara does
not have any field functionaries to motivate the people but ASHA can take the responsibility for the
job. Role of ASHA is in Swajaldhara and TSC is yet to be evolved.
Challenges
1. The key to the successful implementation of NRHM are inter-sectoral convergence,
community ownership steered through Village Health & Sanitation Committees at the level
of the Gram Panchayat and a strong public sector health system with the support from the
private sector.
2. The success of convergent action would depend on the quality of the district planning
process. In the state process of preparation of District Health Action Plans has been
initiated long back but still districts are abandoned with comprehensive plan. Those who
have plan need to revisit yearly to ensure the component of convergence with different
determents. Reflection of integration of different components including – drinking water,
sanitation, women’s empowerment, adolescent health, education, female literacy, early
child development, nutrition, gender and social equality in plans is not sufficient it self Need
is to see the reflection in implementation of activities. After 3 years of NRHM launch there is
hardly few cases of convergence seen with TSC program or Swajadhara program.
Placement of AYUSH doctors at PHC is not the answer of convergence need is promoting
the services of AYUSH as well as utilization of expertise of AYUS in National health
program
4. To promote women’s empowerment, gender and equity, great opportunity is available to
use the services of SHG network. There are more than 35000 SHGs in the State. Through
issue based and target oriented BCC SHGs can be activated for promoting the MCHN &
women empowerment services.
PPP under NRHM in Rajasthan
The National Rural Health Mission (NRHM) aims at providing comprehensive integrated healthcare
to the rural people especially the vulnerable sections of the society, the women and the children.
The Mission recognizes that health status of families is influenced by variety of factors such as
availability of safe drinking water, sanitation, nutrition, social environment etc. Social, cultural and
economic factors play an important role in health status of the individual, family and community. For
achieving the objectives of the Mission and considering gigantic tasks, it is extremely important to
seek support from various private and public partners. There is a great scope of involving non
government bodies, like NGOs, Private Hospitals, Nursing Homes, Private Practitioners, Prominent
Donors most importantly Business Houses who are genuinely concerned about health related
issues, have managerial and financial capabilities and wants to make a positive change in the
existing health scenario.
A Public Private Partnership Cell has been set up within the department of medical and health
under RHSDP. The roles and responsibility of the cell will be to identify the areas for partnership,
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Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
prepare comprehensive policy for PPP in health sector, maintain database of all private agencies,
capacity building, monitoring, evaluation and various studies related to PPP initiatives etc.
Urban RCH Centers in Slum Areas
The Government of Rajasthan has initiated the Urban RCH programme in partnership of NGO/
Hospital/ Private Health Institutions for managing RCH center in identified slum areas for the cities
Ajmer, Alwar, Bikaner, Bharatpur, Jodhpur, Kota and Udaipur on pilot basis. The pilot phase would
be of one year. The NGO/ Hospital/ Private Health Institutions will ensure the availability of the
following: - Health center in the identified slum area, Staff as per guideline for health center and Aid
post ,Equipment, Instruments and furniture as per norms ,Delivery of service as per the project. The
Department will provide all the wages for the staff, appointed by the NGO, recurring cost of the
center along with the amount for medicines equipment and furniture, on quarterly basis after
submission of reports. The Department would also provide drugs, supplies and consumables as
per the provision of budget. In addition to this, an administrative cost would be the NGO to mange
its office at district level, for supervision of I Tier Center.
Development of District Health Plans - Six technical resource agencies were selected for
preparation of District Action Plans for 32 Districts. At State level, one agency was selected to
compile and collate the palns received from district level. These agencies have developed the
District Action Plans with support and involvement of stakeholders like CMHOs, RCHOs, DPMs,
PMOs, etc apart from representatives of different department's like- DWCD, PHED, Education.
NGOs and CBOs are also involved in the process of development of District Action Plans.
MNGO Scheme - To create awareness of RCH services in inaccessible areas MNGO scheme is
implemented in the State. At district level, Mother NGOs are selected. These MNGOs develop an
action plan for inaccessible Villages. The awareness campaigns are implemented through field
NGOs which are identified by MNGO. At present this scheme is functional in 24 Districts and
selection in rest of the districts is in process.
Medical Mobile Units (MMU) - With the objective of provision of health care services at doorstep in
the rural areas, especially in under served areas, 52 Medical Mobile Units are developed. Each Unit
consist of 2 vehicles- one for the movement of doctors and paramedical staff and other is for
services. These units will provide medical facilities in the difficulty hilly and desert terrain, which are
normally not approachable by public transport. The partnership is made with an NGOs in
operationalization of MMUs. NRHM will provide the vehicles with drugs and equipments and NGOs
will arrange for the manpower. These units will be handed over to the NGOs for provision of
Services. Apart from NGOs, private medical collages and hospitals are also the partners in the
scheme.
Trainings - NGOs and Private hospitals are involved in technical trainings. The training of trainers
on blood storage units are conducted in the private hospital. Training of skilled birth attendant is
carried out by an NGO who has a wide experience of utilizing ANM in provision of obstetric services
at grass root level.
Blindness Control- The partnership is made with an NGOs and philanthropic organizations for
provision of services of eyes checkups, cataract operations etc. In this partnership organizations are
involved in awareness generation and logistics arrangements. The services of ophthalmologist,
technical team is mostly provided by the public health Institutions. In the State, eighty percent of
cases of cataract operations are conducted in the camps organized by NGOs.
Involvement in provision of FP services - The private sector institutions are providing quality
health care services to the society. The private institutions are accredited for provision of family
planning services on the set criteria like infrastructure, qualified service providers, technical team,
equipments and drugs etc. The accredited institutions are providing family planning services like
male and female sterilization, IUD insertions, provision of non clinical contraceptives etc. Health
17
Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
Department is providing supplies of contraceptives, required stationary, and some monitory support
to the accredited institutions. The sterilization incentives are also provided to the institutions for
further distribution to the clients who have undergone sterilizations.
Accreditation under Janani Suraksha Yojana - There is provision of Accreditation of minimum
two private institutions for providing delivery services in each block. The process of Accreditation is
initiated in the state and IMA /FOGSI is actively involved. The benefits of the scheme are provided
to the mothers availing services of these institutions.
Hiring of Services of Doctors - There is a shortage of specialists like anaesthetists,
gynaecologists, in the public health system. The areas are identified and the services of services of
specialists, who are working in private sectors, are hired at district level as per the specific tasks
and requirements like sterilization camps, conducting operative delivery. The services of
gynaecologist, anaesthetists are also hired if not available in the institution.
Hiring of Additional ANM, PHN and Lab Technicians - The services of ANM, PHN and Lab
Technicians are being hired through Non Governmental Organizations and private service agencies
at district level.
ASHA Sahyogini trainings-There is a crucial role of NGOs in training of ASHA Sahyogini. The
training is being conducted through selected NGOs at block level. NGOs are involved in logistics
arrangements of the trainings. The NGOs are selected at district level by the committee constituted
under the Chairpersonship of District Collector.
Community monitoring in RCH-II/NRHM - External monitoring and evaluation of health services is
very essential to improve the quality and acceptability of services.
Family Counseling Centers (FCC) - To address the gender based violence from public health
perspective, family counseling centers are established at 8 districts. The FCCs were established
with the objective to provide medical care and professional counseling services to the victims of
violence. NGOs are involved in operationalization of FCCs.
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Compiled & Developed by:
SIHFW
For Health Sector Reforms Workshop
June 19, 2008
Health Sector Reforms in Rajasthan
The Main aim of Health Sector Reforms is




Defining priorities
Refining policies
Reforming Institution
HSR Deals with equity, efficiency, quality and financing
In principles, Health Sector Reforms address to ooverseeing the needs of the entire population
gender sensitive and client friendly, looking forward to the health transition, removing the blind
spot to the private sector, focusing efforts for ensuring quality, efficiency and accountability of
health services
The key elements of Health Sector Reforms are, structural rather than incremental/evolutionary
change, change in policy objectives followed by institutional change, rather than redefinition of
objectives alone, purposive rather than haphazard change ,sustained and long term rather than
one off change, political top down process led by national, regional or local government.
HSR initiatives in Rajasthan






















Jan Mangal Project 1992
Strengthening FRU’s 1994-2001
Decentralized District Planning since 1995-96
Cost recovery mechanism-RMRS-user charges since 1995-96
Reorganizing the Training System 1995-96
Concurrent Evaluation in F.W.Program 1996-97
Promoting private sector in Medical ,Dental & Nursing Education
Draft Training Policy 1997-98
Devolution of Powers to PRI’s - 90’s
Population Policy 2000
Job Responsibilities specifications 2000
Preparation of Essential Drug List 1997 ( 2000 revised)
Health Vision Document 2025
Policy to “Promote Private sector Investment in Health Cara facilities-2006”
“Policy to promote private sector in Health care facilities-2006”\
BPL cards to families for increasing service reach,1997
Contracting out of Capital intensive radio-imaging diagnostics in tertiary care.
Health Insurance for BPL families
Abhilasha Yojana (Preparing women from Self Help Groups for Geriatric care),2007
Patanjali Yojana ( Addressing Non-Communicable diseases,2007
Policy for contracting out PHC/ CHC to private sector,2008
Emergency Management and Research Institute under PPP initiative, 2008
19