Health sector reform initiatives in Gujarat Dr Amarjit Singh Principal Secretary (FW) & Commissioner Health, Medical Services & Medical Education Gujarat

Structural

Pre reform model

Integrated structure

Department of Health & Family Welfare: Govt. of Gujarat

Other Initiatives DPCs AHAs Using ISM professionals Mentoring TCS HMIS Autonomy Capacity building Governance Communitisation

Clear goals

Our Goals Reduce maternal and child mortality Address adverse sex ratio Stabilize population Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia Provide state of the art health and medical education relevant to local needs Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Reducing Maternal and child mortality Chiranjeevi

MMR Over Time Source Time Period Urban Rural NFHS 1992-93 (424) 397 448 NFHS - 2 1998-99 (540) 267 619

Health care facilities available

Availability of OBGYs in CHCs Rural Popu OBGYs Reqd In place Gap Popu/gynec AP 55401067 167 73 94 7.59 C'garh 16648056 118 26 92 6.4 Gujarat 31740767 273 7 266 45.5 M’ashtra 55777647 407 202 205 2.7 MP 44380878 229 13 216 3.41 Raj 43292813 325 109 3.9 India 742490639 3910 1338 2010 5.55

Bonus - saving neonates

SERVICE PACKAGE Service No. of cases Rate Per Case Cost Normal delivery 85 800 68000 Complicated cases Eclampsia 1000 Forceps/vacuum/breech 3 3000 Episiotomy Septicemia 2 6000 Blood transfusion Cesarean (7%) 7 5000 35000 Predelivery visit 100 10000 Investigation 50 Sonography 30 150 4500 Dai Transport 200 20000 Grand total 179500

Gynecologist involvement in Chiranjeevi District Total OBGY Specialists in the district # enlisted under Chiranjeevi scheme Total # of deliveries Performed Average delivery per Doctor BK 50 65 19407 299 Dahod 18 10 24038 2404 Kutch 47 11302 628 P'mahal 29 34 30509 897 SK 73 23818 476 Total 217 177 109074 616

Chiranjeevi Yojana Report June -08 Ending (20 Districts) Sr # District Name Normal LSCS Complicated Total % LSCS # of Doctors Enrolled 1 Gandhinagar 2070 303 165 2538 11.94 24 2 Mehsana 10905 953 772 12630 7.55 42 3 Patan 11780 1089 357 13226 8.23 36 4 Ahmedabad 20494 803 21297 3.77 195 5 Kheda 3545 489 109 4143 11.80 31 6 Anand 4691 882 17 5590 15.78 32 7 Surendranagar 5676 335 80 6091 0.00 27 8 Vadodara 5143 441 5779 3.37 52 9 Bharuch 1856 264 176 2296 11.50 21 10 Narmada 825 51 59 935 5.45 11 Surat 2471 157 60 2688 5.84 69 12 Navsari 2270 353 96 2719 12.98 18

Chiranjeevi Yojana Report June -08 Ending (20 Districts) Sr # District Name Normal LSCS Complicated Total % LSCS # of Doctors Enrolled 13 Valsad 2110 238 63 2411 9.87 21 14 Ahwa-Dang 407 36 5 448 8.04 4 15 Rajkot 3461 178 81 3720 4.78 49 16 Jamnagar 1100 31 7 1138 2.72 17 Bhavnagar 1824 206 38 2068 9.96 10 18 Amreli 383 41 19 443 9.26 Junagadh 973 157 40 1170 13.42 20 Porbandar 703 188 907 20.73 20 District Total 82687 6949 2601 92237 7.53 695 22 5 District Total 93118 5465 10491 109074 5.01 177 23 25 District Total 175805 12414 13092 201311 6.17 872

Chiranjeevi State 2007-08 & 2008-09

201311 805 39 766 7650 829 6820 Outcome of Chiranjeevi Scheme: Mothers & New Born babies saved Total Deliveries under Chiranjeevi scheme Expected Maternal Death Maternal death reported under Chiranjeevi scheme Mothers saved under Chiranjeevi scheme Expected New born death New born death reported under Chiranjeevi scheme New born saved 201311 805 39 766 7650 829 6820 Normal Deliveries: 175805 C-Section: 12414 (6.17%) Complicated Deliveries: 13092 (6.50%) Private specialist enrolled: 872/2000

Institutional deliveries trend

Extended Chiranjeevi and Bal Sakha

Our Goals Reduce maternal and child mortality Address adverse sex ratio Stabilize population Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia Provide state of the art health and medical education relevant to local needs Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Mass Media Takes keen Interest

Political commitment on the floor of the house.

Sex ratio at birth as per CRS records

4 Districts showing deterioration in sex ratio Name of the Talukas Sex Ratio -2004 Sex Ratio- 2006 Ahmedabad City 850 818 Amreli 826 801 Kukavav Vadia 807 707 Bagasara 883 785 Anand 813 790 Sujitra 930 855 Petlad 849 779 Visnagar 789 Mehsana 814 774 Kadi 854 843 Chansama 758 751 Rajkot 852 773 Upleta 860 811 Jetpur 897 767 Dhoraji 842 832 Surat City 786 781 Wadhvan 865 815 4 Districts showing deterioration in sex ratio Name of the Districts Sex Ratio -2004 Sex Ratio- 2005 Ratio- 2006 Surat 815 794 796 Kutch 877 930 920 Jamnagar 860 871 Kheda 830 904 878 State average: 870 (2006)

Our Goals Reduce maternal and child mortality Address adverse sex ratio Stabilize population Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia Provide state of the art health and medical education relevant to local needs Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Special Initiatives for NSV

Crude birth rate

Our Goals Reduce maternal and child mortality Address adverse sex ratio Stabilize population Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia Provide state of the art health and medical education relevant to local needs Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Effective Implementation of national health programmes in PPP Working with IMA Outsourcing CD4 testing MNGOs, SNGOs and FNGOs Working with Rotary and Lions GIA institutions Outsourcing staff Working with private OBGYs

Cure Rate Vs Case Detection Rate (3Q06/3Q07)

Cataract Surgical Rate (CSR) (2003-08)

NLEP – Gujarat Endemicity as on May.08 P.R.-0.78 PM Dahod 1.80 2.36 Vadodara 1.31 Bharuch Narmada > 5 2 - 3 1 - 2 < 1 P.R. 3 - 5 2.80 1.91 Surat 1.50 Dang Navsari 3.49 2.58 Valsad 2.81

SECONDARY & HIGHER SECONDARY SCHOOL Specialist services under school health programme INSTITUTE HEART KIDNEY CANCER ANGANWADI CENTERS 473 60 23 PRIMARY SCHOOL 3703 484 159 SECONDARY & HIGHER SECONDARY SCHOOL TOTAL 4176 544 182

Route Map through Satellite based monitoring system Max. distance Desert Start

Curative services through MHUs Retrospective Status Satellite based Monitoring System implemented

Our Goals Reduce maternal and child mortality Address adverse sex ratio Stabilize population Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia Provide state of the art health and medical education relevant to local needs Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

PPP in ME Medical colleges in PPP with Bombay hospital; United phosphorous; Narayan Rudalaya and Fortis Setting up of PHFI Gujarat Nursing colleges Outsourcing staff; security; laundry Outsourcing diagnostics Outsourcing lab work

MOU s SIGNED VIBRANT GUJARAT

Our Goals Reduce maternal and child mortality Address adverse sex ratio Stabilize population Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia Provide state of the art health and medical education relevant to local needs Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

NOVEL INITIATIVES Institute of Kidney Diseases and Research Centre (IKDRC), U.N.Mehta Institute of Cardiology and Research Centre and Gujarat Cancer Research Institute are government funded institutes, administered by various private organizations. RKSs EMRI 108 To increase utility and performance of various government health facilities they are being run by private and local CBOs. Project Implementation Unit (PIU) a novel venture by Gujarat Government to undertake infrastructure development aggressively NABH/NABL HMIS

EMRI - 108

EMRI EMRI is a non-profit organization based on the Public Private Partnership (PPP) model in Gujarat. The service is currently available in parts of Gujarat through the toll free number 108. By August end 400 ambulances will serve the whole state. The pre hospitalization emergency care provided by EMRI is free and the patient is admitted to a hospital of his or her choice. More than 400 hospitals in the state collaborating with EMRI to stabilize the patient brought in, free of charge. Massive capacity building Setting up of EMS authority and EMS Act

Trauma care EMS act EMS authority Extensive planning for trauma care Trauma care services A total of 93053 emergencies have been attended 39% 31613 trauma related 16% 13224 pregnancy related 291 pregnancies handled in the ambulance. 181 trauma care units already operational 4.4 dispatches per ambulance daily All 400 to be operational by August 2008.

Running CHCs and PHCs in partnership with CBOs

PERFORMANCE INDICATORS Name of Facility Pre PPP Performance Post PPP Performance Community Health Center O.P.D. I.P.D. CHC Shamlaji Dist Sabarkantha 75 9 175 20 CHC Mota Pophalia Dist Baroda 65 10 69 CHC Malav Dist Panchmahal 35 3 149 23 Primary Health Center   PHC Chansad Dist Baroda 1015 1155 14 PHC Dahej Dist Bharuch 1236 5461 134 PHC Matano Mad Dist Kutch 239 5 290

Better infrastructure with PIU

PROJECT IMPLEMENTATON UNIT GUJARAT Project Implementation Unit is setup for repairs, strengthening, retrofitting and new construction work of Healthcare Structures. High level expertise in hospital design & structural engineering aspects available on an outsourcing basis. Rigorous management information system with Gantt charts to ensure that the completion schedule are followed. The quality of the construction maintained through third party monitoring & supervision agency. Consultants / Experts are appointed for various services i.e. architectural planning, structural design, sanitary & plumbing design, electrical design, landscaping etc.

Repair, Strengthening, Retrofitting & Reconstruction (RSRR) Name of Work RSRR Works Number of Structures 1023 Details of Structures (Type) GH CHC PHC Disp SC SQ Total No of Structures 4 50 121 7 300 541 Cost 68.30 Crores Present Status Completed

New Construction Works ( Health Facilities + ICDS) New Construction of Health Care & ICDS Facilities Name of Work New Construction Works ( Health Facilities + ICDS) Number of Structures 904 Total Structures CHC PHC AH Disp SC SQ TB Clinic CDPO + Angan. CMSO Total 1 28 3 7 48 329 484 4 Cost 108.62 Crores Present Status 76% of work completed

NABH/NABL ACCREDITATION 1ST PHASE (2007-08) Food and drugs administration lab already accredited by NABL 8 District Hospitals (NABH) 1 Medical Colleges (NABH) 6 Medical Colleges (NABL) 2ND PHASE (2008 -10) 18 District Hospitals 5 Medical Colleges

PATIENT SATISFACTION

Making sense of data Enhanced patient care and effective use of resources with HMIS

Technical Architecture [Three Tier ] Network Architecture - Health & Family Welfare Department Govt. of Gujarat Topic : Technical Architecture [Three Tier ] The screen shows the manner in which the network works for HMIS. There is a central server which connects the local servers of each location to itself. The firewall will restrict the anonymous access to the central site. HMIS Technical Architecture Think Life ...

Hospital Management & Information System (HMIS) Patient Care Services Clinical Services Hospital Admin Ancillary Services Registration Wards Pharmacy Billing Patient Education Information Kiosk Nursing Care Clinical/EMR (Gynecology, Ophthalmic, Orthopedic, ENT, Gastro Medicine, General Medicine, Nephrology, Pediatric, Surgery, Urology, Skin etc…) Laboratory (Pathology, Microbiology, Bio Chemistry, Radiology) Blood Bank Imaging Hospital Admin Human Resource Payroll Financial Accounting Stores/Inventory Purchase Complaints & Redresses Transportation MIS Reports EIS Reports National Programs Linen Management Equipment Maintenance Resource Scheduling Special Camp & Training Bio Medical Waste Application Security

Management Information System - Data Flow State Level Monitoring Expected Users : Health Minister, Commissioner, Secretary Top Management All Programs like D & E, Malaria, etc… Expected Users: Program Owner Health Department Data Daily Dashboard Expected Users: Hospital Superintendent Hospital Senior Management Disease Report, Death Report Expected Users: Doctors, Nurses, Admin Staff Users Of HMIS at District Hospital

Blocks performing poorly

Institutional Deliveries – Vadodara Region Bharuch Vagra Narmada Nandod Dediapada Sagbara Vadodara Nasvadi Kawant Chota Udaipur Dahod Halol Panchmahal Ghoghamba

Institutional Deliveries – Panchmahal District

Institutional Deliveries in the PHCs in a Block in Panchmahal District

Our Goals Reduce maternal and child mortality Address adverse sex ratio Stabilize population Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia Provide state of the art health and medical education relevant to local needs Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Capacity building Reservation of seats in PG seats Sri Chitra AMA TISS PHFI CORT SIDA UNICEF WHO fellowships Mentoring Awards for PP partners and our own staff

Our Goals Reduce maternal and child mortality Address adverse sex ratio Stabilize population Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia Provide state of the art health and medical education relevant to local needs Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Integrated disease surveillance Response begins PRIM HC REP SAMP RES Potential cases prevented CASES DAY

Issues Malnutrition Neonatal health Unmet need for FW Sex ratio PPP initiatives Filling up of places Improving satisfaction with health care facilities Health infrastructure development corporation Capacity building

Thank you Thank you Department of Health Government of Gujarat