Retaining skilled health Human Resources for Rural and Remote areas a mapping of efforts under NRHM and ongoing studies in this area:
The NATIONAL RURAL HEALTH MISSION paradigm shift Health is a state subject. Only family welfare is a central subject Most institutions and manpower are in the state sector. Most functional programmes are in the central sector and they cover only 19% of all morbidites : This is mainly: RCH (From Family planning to family welfare to CSSM to RCH-I to RCH-II) And Disease Control programmes But programmes for their success need viable health systems and health systems need to address wider range of health issues Now with NRHM- central government is funding health systems and not confined to health programmes
NRHM approach to funding state health systems: Funds State programme implementation plan(pips); which are based on district plans-drawn up by the state. Sector wide approach- comprehensive horizontally integrated health plans: It sets down a minimum set of service guarantees and minimum infrastructure requirements that would define access to services. Calls for reform or architectural correction of health systems to make it functional
NRHM The Normative IPHS structure: Accredit private providers for public health goals 30-40 Villages 30,000 popn. 100,000 Population 100 Villages CHC- BLOCK HOSPITAL 7 doctors including 4 specialists, 9 nurses Obstetric/Surgical Medical Emergencies Ambulance Round the Clock Services; THE PRIMARY HEALTH CENTER 2 MOs; 3 Staff Nurses; Ayush Doctor; three technical support staff, 1 LHV and one male supervisor Ambulance; Round the Clock Services Health Manager Accountant storekeeper Strengthen Ambulance/ Transport Services Increase availability of Nurses Multi-skill for specialists Encourage fixed day clinics for special services. Clear service guarantees & STGs for each level of service. 5-6 Villages 5000popn. 1 village GRAM PANCHAYAT- THE HEALTH SUB-CENTER 2 ANMs, 1 male MPW FOR 5-6 Villages; Telephone and referral Link; VILLAGE LEVEL- ASHA, AWW,VHSC 1 ASHA In every hamlet, 1 AWWs in every village; a Drug Kit,
Indian Public Health Standards: Achieving fully functional health faciltiies IPHS specifies package of services that the sub-center, the PHC, the CHC and the district hospital would provide. IPHS specifies the desirable minimum population norms for facility creation. IPHS specifies the minimum infrastructure, equipment and supplies that each of these facilities should have for provision of quality care. IPHS specifies the desirable number of skilled human resources that should be available in each of these facilities. NRHM provides funds to close gaps between what is available and what is needed. NRHM provides for monitoring to see whether these funds are being utilised and how far we are progressing towards the goal of IPHS.
NRHM DIRECTIONS OF REFORM DECENTRALIZATION & STRENGHTENING COMMUNITY PROCESSES MONITOR, PROGRESS AGAINST STANDARDS. FLEXIBLE FINANCING IMPROVED INSTITUTIONAL & PROFESSIONAL & MANAGEMENT SKILL DEVELOPMENT INNOVATION IN HUMAN RESOURCE MANAGEMENT.
Human Resource Densities in the public health sector Population Density of Professional service provider Density of all health service providers Density of all health workers Density of all HWs including ASHAs potential or existing WHO norm( public + private) 2.280 IPHS normative dt 18,00,000 0.980 1.55 1.92 2.92 Vellore health district 18,01,000 0.610 0.73 0.81 Dausa Rajasthan 15,54,142 0.320 0.44 0.55 1.55 Janjgir, Chhattisgarh 1505,000 0.150 0.33 0.42 1.41(3.4)* Muzzafarnagar, Uttar pradesh 40,22,255 0.160 0.23 0.27
Poor public sector densities- three factors Not enough facility density: not enough facilities have been created. Not enough sanctioned posts in existing facilities.( far less than IPHS norms in almost all states) Not enough candidates attracted or retained in posts that have been created. In last three years over 75,000 staff have been added into the public health systems.
Bonding and compulsion strategies.. 1. Compulsory rural postings- Bonds- limited effect in most states eg: Assam 5 year bond forfeit Rs 0.7 million. Chhattisgarh- 2 year bond forfeit 0.1 million 1. Rural Service as pre-qualification for PG admission: effective in most states but poor quality and transient. Chhattishgarh, Orissa, J&K, Bihar. 3. Reservation of seats or preference for rural service in postgraduate selection. varies from reserving 50 to 100% of seats in tamilnadu, to additional marks in entrance examination etc.
Workforce environment changes 1. Contractual appointments made to the facility- contractual mode supposed to help in different areas. 1. avoid pressure to transfer to urban areas the residency criteria... 2. Increase accountability 3. Simpler process of recruitment and deplument 2. Fair transfer policy- rotational postings and career paths tamil nadu, karnataka.. 3. Pooling of medical officers: West Bengal, Bihar, Jharkhand, insurgency areas in chhattisgarh.( DASS- difficult area support system)
Better compensation packages and financial incentives.. Almost all states have introduced many measures: One common theme is stratification into 3 levels of difficulty and an incentive for each level. Other forms like night duty allowance, performance based incentives. Also introduced. Promotions and cadre restructuring has also been promoted.
PPP options as HR solutions Contracting-in options. 1. Madhya Pradesh for specialists: Contracting-out options. 1. Arunachal Pradesh; of PHCs to Karuna trust.. 2. Bihar: Of PHCs; of diagnostics, of district planning.. 3. Gujarat: PHCs, CHCs and a district hospital.& CHIRANJEEVI: Evaluation studies available. 4. Punjab: village level dispensaries
Multi-skilling for Increasing availability of skilled in priority areas.. 1. Medical officers to play specialist roles: emergency 2. Ayush doctors for medical officer roles. 3. Nurse practitioners to fill in for doctors 4. Pharmacists- three year paramedicals providing curative care. 5. Male multi purpose workers and supervisors into multiskilled workers to provide a set of support services of the PHC. Alternative service providers/task shifting: On going study to test the effectiveness of these strategies in Chhattisgarh state
Educational Recruitment Strategies The West Bengal case study- for nurse midwives The Chhattisgarh Mitanin initiative for nurse midwives- 1000 community health volunteers taken into the programme.
The West Bengal Case Study: Needed 10,000 ANMs more: Revived 18 existing ANM schools Entered into a partnership with 23 private institutions for private ANM schools Intake increased to 3400 students per year. Three year time frame- first batch joins in November. Residency as criteria as selection. Selection and ownership by panchayats.
Expanding professional education: Two key questions: Should we attempt crafting new types of medical and nursing and para-medical colleges in the public sector or should we leave it to private sector or PPPs and that too under the current councils. Do we have conceptual models or international role models that could be promoted? Should we focus on approaches where sections from rural areas and under-served areas gain preferential access to educational opportunities and conditions are built by which they can return and serve in these areas and yet have a reasonable career path.
In service- qualification human resource generation Public health management- one year diplomas residential and distance education mode. First batch just completed. Family medicine diploma in distance education mode and degrees with residential skill training.( 120 starting up this year) Epidemiologists through one year distance education mode.
The PHRN-NHSRC Initiative Focus on distance education mode- 18 month programme. With 3 week contact programme in 3 rounds. High degree of mentorship and follow up at the district level. Content : District Health Plan for NRHM Implementation of District Health Plans Tools for Planning: Tools of management: Teaching of Perspectives Focus on integration and convergence Integrated with practice and the promotion of change within the system. Ongoing in over 50 districts. Potentially need to create a public health team in every district and then a team in every block which can provide public health leadership. Need to evaluate experience on this.
THANK YOU