Decentralisation Initiatives in Gujarat Health Sector Reforms Department of Health & FW Government of Gujarat Decentralisation Initiatives in Gujarat Health Sector Reforms Department of Health & FW Government of Gujarat

Gujarat – A Profile Overview Area196,000 km6% of India Population50.5 million5% of India Urbanization37%India avg. 28% SDP ( ) Rs 1, billion (€ bill.) 6.33% of India Per Capita Income ( ) Rs 26,979 (€ ) India average - Rs. 20,989 (€ ) 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 earthquake the State Programme Implementation Unit established to 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 Approval from Dy.Eng Administrative sanction by CDHO Technical Sanction by Executive Engineer Repair carried out ? Repair required Write to Deputy Engineer Inspection by Section Officer Prepare plan & estimates Earlier Total dependence on R&B

Major stakeholders involved and their role Now SOE submitted to District RCH society Fund released to MO for minor repairs Repairs carried out by MO through private agency

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) Minor Structures (Disp, SC,SQ) Total

Progress Report NC -1 ParticularsTotal StructuresUnder Progress Total Cost (Rs. in Crores) AH PHC66 Disp31 SC95 Staff Quarters24596 Total264108

POST EARTHQUAKE REDEVELOPMENT PROGRAMME NEW CONSTRUCTION (Pipeline) ParticularsTotal Structures Total Cost (Rs. in Crores) CHC1 76 crores AH1 PHC22 SC45 DISP4 TB clinics1 Staff Quarters113 Aganwadies472 CDPO12 Total676

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 from 3.0 to 2.1 by 2010

Maternal Mortality: UK 1840–1960 Improvements in nutrition, sanitation Antibiotics, banked blood, surgical improvements Antenatal care Maine 1999.

Maternal Mortality Reduction Sri Lanka 1940– % births attended by trained personnel

Three Delays Responsible for Maternal Deaths 1. 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 2. Delay in reaching care ( Community & System)  Lack or underutilization of transport funds  Non availability of referral transportation in remote places  Lack of communication network 3. Delay in receiving care (System)  Poor facilities, personnel and Supplies  Poorly trained personnel with indifferent attitude

Service Charges for participating Gynecs Normal delivery Normal delivery Complicated cases Eclampsia Eclampsia1000 Forceps/vacuum/breech Forceps/vacuum/breech Episiotomy Episiotomy800 Septicemia Septicemia Blood transfusion Cesarean (7%) Cesarean (7%) Predelivery visit Predelivery visit Investigation Investigation Sonography Sonography Dai Dai Transport Transport

Chiranjivi preliminary results Districts Gynecs enrolled Deliveries conducted Kutch1848 Banaskantha39349 Sabarkantha37254 Dahod13212 Panchmahals22206 Total

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 Kachchh Jamnagar Rajkot Banaskantha Surendranagar Ahmedabad Mahesana Patan 1 Measles 2 Diptheria 5 Measles 2 Measles, 4 Diphtheria 1 Measles

Next phase of reforms  Strategic planning cell  Functional management Computerised financial management, budgeting, and auditing Computerised financial management, budgeting, and auditing Monitoring and evaluation functions Monitoring and evaluation functions HRD systems 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. 

Government of Gujarat and European Union a fruitful partnership January 2006

Trends in leading causes of deaths

National RNTCP Status – 2Q04/2Q05 Case Detection Rate Cure Rate

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