Decentralisation Initiatives in Gujarat

Health Sector Reforms Department of Health & FW Government of Gujarat

Gujarat – A Profile

Overview

Area Population Urbanization SDP (2003-04) Per Capita Income (2003-04) ( 196,000 km 50.5 million 37% Rs 1,425.60 billion ( € 26.40 bill.) Rs 26,979 € 496.24) 6% of India 5% of India India avg. 28% 6.33% of India India average Rs. 20,989 ( € 388.69)

The Planning Commission has set a target growth rate of 10% p.a. for Gujarat

Background  The Sector Investment Programme (SIP) started in Gujarat in January 2000, initially in two districts, Narmada and Rajkot  Following the earthquake in January 2001, 9 affected districts were also taken up to implement Reforms with Reconstruction  In January 2005 the remaining 14 districts were also covered under the SIP, making a total of 25 districts

Institutional mechanisms

 The State Health Sector Reform Cell constituted in 1999 for the EC supported SIP  Standing Committee On Voluntary Action was created in early 2000 to expedite the disbursement of funds  The Reconstruction Sub Committee constituted in 2002 for post earthquake activities

 Following the Implementation earthquake Unit the established State to Programme manage and administer the Repairs and Reconstruction of health facilities.

 DPIUs were established to monitor and supervise the Repair and Reconstruction works at local level.

 District Agencies at the district level to manage the reform component. They prepared their own District Action Plans in consultation with the community and the health functionaries to meet the local needs.

 Flexibility in re-allocation of funds at the State and the District level according to the need and priority.

SRC RSC SPIU DPIU District agency

Government Policy Resolutions

1.

Delegation of Powers to Medical Officers PHCs, District Societies and Additional Director (Family Welfare) 2.

Delegation of financial and administrative powers to Medical Colleges, District Hospitals, Community Health Centres (CHCs) and PHCs 3.

Establishment of Block Health Offices (BHOs) 4.

Formation of Rogi Kalyan samities

Decentralisational processes in repair and reconstruction

Earlier

Total dependence on R&B Prepare plan & estimates Approval from Dy.Eng

Inspection by Section Officer Administrative sanction by CDHO Write to Deputy Engineer Technical Sanction by Executive Engineer Repair required Repair carried out ?

Major stakeholders involved and their role

Now

Repairs carried out by MO through private agency SOE submitted to District RCH society Fund released to MO for minor repairs

Monitoring and Evaluation

 Monthly Physical and Financial Progress Report (SOE)  Supervisory visits by state and district program managers  Review in District RCH society meetings and review in state and district level meetings

Issues

 Lack of trust and fear - Funds could not be utilized in a few districts where District RCH societies did not release fund to MO  Fund flow to MOs delayed due to lack of Bank Account but now streamlined  Proper orientation to stake holders on purpose, process and output required  Delegation of powers only for donor agency fund, now being institutionalised

Work carried out by PIU (RSRR)

Particulars Total Structures Provisionally Handed Over Under Progress Total Cost ( Rs. in Crores)

Major Structures (GH, CHC,PHC) 177 58 118 Minor Structures (Disp, SC,SQ) 853

Total 1030

419

477

434 59.06

552

Progress Report NC -1

Particulars

AH PHC Disp SC Staff Quarters

Total Total Structures Under Progress

2 6 0 6 3 1

Total Cost (Rs. in Crores)

9 5 33.60

245 96

264 108

POST EARTHQUAKE REDEVELOPMENT PROGRAMME NEW CONSTRUCTION (Pipeline)

Total Cost (Rs. in Crores) Particulars

CHC AH PHC SC DISP TB clinics Staff Quarters Aganwadies CDPO

Total Total Structures

4 1 113 472 12

676

1 1 22 45 76 crores

Chiranjivi

OBJECTIVES-

Vision 2010, Population Policy & RCH II

   Reduce MMR from 389 (in 1998) to 100 per 100,000 live births by 2010 Reduce IMR from 60 to 30 by 2010 Stabilize population by reducing TFR from 3.0 to 2.1 by 2010

Maternal Mortality:

UK 1840 –1960 500 400 300 200 100 Maternal Deaths 0 18 40 18 50 18 60 18 70 18 80 18 90 19 00 19 10 19 20 19 30 19 40 19 50 19 60

Improvements in nutrition, sanitation Antenatal care Antibiotics, banked blood, surgical improvements

Maine 1999.

Maternal Mortality Reduction

Sri Lanka 1940 –1985 2000 1600 1200 800 400 0 1940–45 1950–55

85% births attended by trained personnel

1960–65 1970–75 1980–85

Three Delays Responsible for Maternal Deaths

1.

2.

3.

Delay in deciding to seek care

 (Individual & family) Lack of understanding of complications    Gender issues, Low status of women Socio-cultural barriers to seeking care Poor economic condition of the family

Delay in reaching care

 ( Community & System) Lack or underutilization of transport funds  Non availability of referral transportation in remote places  Lack of communication network

Delay in receiving care

 (System) Poor facilities, personnel and Supplies  Poorly trained personnel with indifferent attitude

Service Charges for participating Gynecs

Normal delivery Complicated cases Eclampsia Forceps/vacuum/breech Episiotomy Septicemia Blood transfusion Cesarean (7%) Predelivery visit Investigation Sonography Dai Transport 85 3 7 100 2 3 100 30 100 100 800 68000 1000 1000 800 3000 1000 5000 100 50 150 50 200 3000 6000 3000 35000 10000 5000 4500 5000 20000 179500

Chiranjivi preliminary results

Districts

Kutch Banaskantha Sabarkantha Dahod Panchmahals Total

Gynecs enrolled

18 39 37 13 22 129

Deliveries conducted

48 349 254 212 206 1069

HRD Reforms



Grading of PHCs, CHCs and special training for poorly performing districts – manual for MOs – web site



Three month PDP for district and block level officers



“Karma yogi” motivational training program to change the attitude of government employees- conceptualized by Hon. Chief Minister



PG seats reserved for admissions to doctors serving in rural areas - regular deputation for DPH programmes



Computerised data base for doctors



Filling up of vacant posts of MPHW by SI - three month Bridge course for sanitary inspectors

Innovations

 Web based Integrated Disease Surveillance Programme  Improved MIS through computer applications- RCH software;  Transparency - information sharing through web site  CRS  GIS application – spatial distribution of health fcailities - Village wise data for malaria, and RCH  Urban health  NGOs

Innovations 2

 Decentralised recruitment of Medical Officers Powers of ad-hoc appointment delegated to RDDs  Chiranjivi  Rogi kalyan Samiti  Computerisation of hospitals  Telemedicine  MCCD

Integrated Disease Surveillance

1 Measles 2 Diptheria 5 Measles

Banaskantha Mahesana Patan Kachchh Jamnagar Rajkot Surendranagar Ahmedabad

1 Measles 2 Measles, 4 Diphtheria 1 Measles

Next phase of reforms

        Strategic planning cell Functional management  Computerised financial management, budgeting, and auditing   Monitoring and evaluation functions HRD systems Extensive use of IT Decentralised management through RDDs Outsourcing CHCs and DHs Revamped CMSO Communitisation - effectiveVillage health societies Ombudsman

Further Information

 PROD reference number 2: Medical Officers authorised to arrange maintenance and repairs on Primary Health Centres, Gujarat.

 PROD reference number 31 Establishment of District Health Agencies to manage health services, Various States.

 www.prod-india.com

Government of Gujarat and European

Union a

fruitful partnership

January 2006

25

Trends in leading causes of deaths

Circulatory System 20 Infectious & Parasitic 15 Symptoms, signs and ill defined Injury & Poisoning 10 5 Certain condition originating Respiratory system 0

84 -8 5 85 -8 6 86 -8 7 87 -8 8 88 -8 9 89 -9 0 90 -9 1 91 -9 2 92 -9 3 93 -9 4 94 -9 5 95 -9 6 96 -9 7 97 -9 8 98 -9 9 99 -0 0 00 -0 1 01 -0 2 02 -0 3 03 -0 4 04 05 -0 -0 6 5 (J un -0 5)

Cataract Surgery rate Achieved per one lakh population (Year 2001-02 to 2004-05) 1000 950 900 850 800 750 700 802 Year Cataract surgery 815 846 863 941

2000-01 2001-02 2002-03 2003-04 Cataract Surgery Rate 2004-05

National RNTCP Status – 2Q04/2Q05

100% 95% 90% 85% 80% 75% 70% Bihar J&K Punjab Chattisgarh UP Uttaranchal Kerala Maharashtra Manipur Jharkhand Haryana Karnataka MP Assam Orissa Meghalaya Nagaland Mizoram Chhatisgarh Rajasthan Gujarat AP TN WB HP Arunachal Pradesh Sikkim Delhi INDIA 65% Pondicherry 60% 55% 50% 20% 30% 40% 50% 60% 70% 80% Case Detection Rate 90% 100% 110% 120%

School health programme

 School check up for 10 million children annually  1.6 million students treated on site; 75,000 students referred for tertiary care; more than 70,000 children given spectacles  More than 5000 children provided super specialist heart, kidney and cancer care at Government cost

Referral Services under School Health Programme (2004-05) Ophthalmic surgeon -

32304

Dental surgeon -

10346

Skin specialist -

4872

E.N.T. surgeon -

6245

Pediatrician -

17679