NRHM PIP 2009-10 Department of Health & Medical Education Government of Jammu & Kashmir 2nd March 2009 PREFACE Though the State has been rather late in gearing up for effective implementation of the NRHM, there has been a substantial increase in the levels of activities over the past couple of years. The realization that the NRHM provides an excellent mechanism and opportunity to rejuvenate and strengthen the rural health system has grown enormously. This has led to serious thinking about the possible solutions to the bottlenecks being faced in the implementation of the programme. The implementation of NRHM has been affected mainly due to certain key factors such as shortage of doctors (particularly specialists and nurses) especially in rural and remote areas, serious shortages in the availability of infrastructure, non-implementation of JSY, inadequate systems for procurement and rather inadequate community effort. The State has, accordingly, decided to remove these gaps taking full advantage of the NRHM in a focused and effective manner. There has been a realization that payment of meagre emoluments to contractual doctors has been a major reason for non- availability of contractual doctors particularly in rural and difficult areas. It is, therefore, proposed to increase the remuneration of contractual doctors and paramedical staff. Additional financial incentives are also being proposed for doctors (in-service and contractual) working in notified difficult areas. In addition to these measures, the State is contemplating several measures to improve conditions of service of doctors especially those serving in difficult areas. Two years rural service has been made mandatory for the PG entrance examination. 10% seats in the PG courses are reserved for those who have served in rural areas for 5 years. Now, additional financial and non-financial incentives are under consideration. These include better avenues of promotion to the specialists, additional weightage in the PG entrance examination for service in notified difficult areas, linkage of time-bound promotions to service in certain category areas etc. The approach is to 2 make whatever efforts resources permit to provide doctors in rural and difficult areas. When health services are made available to the people closer to their door-steps in the remote areas of the State, targets under NRHM can be achieved while reducing avoidable load from secondary and tertiary sectors. Needless to emphasize, close and regular monitoring and evaluation of work done as well as referral audits would also be required to enhance accountability. Simultaneously, we realize the serious gaps in our infrastructure. To explain the present scenario 19 % of CHCs/SDHs, 59 % of PHCs and 89 % of HSCs, are housed either in rented buildings or have insufficient accommodation. The level of health services that are possible to deliver in this situation can be well imagined. A large number of building works have been taken up in the past and the cost of completing these is huge. The State had earlier prepared a project for World Bank funding for providing funds for health infrastructure. Subsequently, the State was advised by the Govt. of India to explore the possibility of accommodating this requirement under NRHM. The State has prepared a comprehensive proposal for infrastructure development. This includes requirement for much needed equipments. The State will, however, provide for the creation of staff positions as required. Resources need to be provided in adequate measure for this purpose. The focus will be on completing on-going works and filling up critical gaps in the shortest possible time without seeking expansion. Need has also been felt to take urgent steps to reduce the excessive burden on the two main maternity hospitals at Srinagar and Jammu. The State has already proposed construction of two new 400 bedded maternity hospitals at Srinagar and Jammu. The proposal of the State needs to be supported. The implementation of JSY was stopped in April 2007, although, subsequently only the ASHA component was allowed. Now, it has been realized that this has adversely affected the progress under NRHM. The previous decision has, accordingly, been reviewed and the 3 implementation of JSY has been resumed with adequate safeguards recently. It is now expected that expenditure under JSY will increase and so will the institutional deliveries. Another major hindering factor in the past has been inadequate systems of procurement. Procurement through a centralized purchase committee in the Secretariat which was cumbersome and inefficient has been done away with. Procurement has been decentralized to a substantial extent. The state is also contemplating to set up a dedicated Directorate for procurement of medical supplies which will attend to this task on a full time basis, replicating thereby the TNMSC model in a state specific manner. Lastly, the State could not achieve the desired communitization as envisaged under NRHM. This is chiefly because PRIs are not in place. As such, it has been decided to involve other community based organizations existing in the villages. It is proposed to focus on capacity development of Village Health and Sanitation Committees (VH&SCs) to achieve effective mobilization of community effort. The State will also focus on a State specific IEC strategy which is result oriented. While the State makes concerted efforts to address the bottlenecks in a focused manner, the necessity for central support and assistance cannot be over-emphasized. Now that the structures are in place and functioning, and specific efforts are being made to remove the bottlenecks, the implementation of NRHM is expected to register substantial improvement in the forthcoming year. 4 CONTENTS PREFACE EXECUTIVE SUMMARY PREAMBLE PROGRESS MADE PROPOSED ACTIONS PRIORITIES FOR 2009-10 RESPONSE TO COMMENTS /SUGGESTION BY VARIOUS DIVISION OF MINISTRY 1. SITUATIONAL ANALYSIS- GEOGRAPHIC, DEMOGRAPHIC & SOCIO ECONOMIC HUMAN RESOURCES FOR HEALTH –ISSUES, INTIATIVES HEALTH SYSTEM INFRASTRUCTURE HEALTH SERVICES A RCH-II B. NATIONAL DISEASE CONTROL PROGRAMME C. NRHM INITIATIVES 2. TECHNICAL COMPONENTS PART A- RCH-II PART B- NRHM INITIATIVES PART C- IMMUNIZATION PART D- NATIONAL DISEASE CONTROL PROGRAMME PART E- INTERSECTORAL CONVERGENCE ANNEXURES A. STATUS OF TRAININGS B. BUDGET SHEETS OF TRAININGS & WORKSHOPS C. BUDGET SHEETS (STATE & DISTRICT DISTRIBUTION) 5 ABBREVIATIONS ANC Ante natal Care ANM Auxiliary Nurse and Midwife ASHA Accredited Social Health Activist CHC Community Health Centre CMO Chief Medical Officer DoHFW Department of Health and Family Welfare DH Block Hospital ENMR Early Neo-natal Mortality Rate EmOC Emergency Obstetric Care EAP Externally Aided Projects FRU First Referral Unit FNGO Field NGO HMIS Health Management Information System HIV Human Immuno-deficiency Virus IPHS Indian Public Health Standards ISM Indian System of Medicine IMNCI Integrated Management of Neo-natal and Childhood Illnesses JSY Janani Suraksha Yojana IMR Infant Mortality Rate NMR Neo-natal Mortality Rate MTP Medical Termination of Pregnancy MMR Maternal Mortality Rate MNGO Mother NGO MO Medical Officer MH Maternal Health NNMR Neo-natal Mortality Rate NGO Non-Government Organization NRHM National Rural Health Mission NAMP National Anti Malaria Programme NLEP National Leprosy Eradication Programme NKAP National Kala-Azar Programme NFP National Filaria Programme NIDDP National Iodine Deficiency Disorder Programme NBCP National Blindness Control Programme OPD Out Patient Department PNMR Primary Neo-natal Mortality Rate PHC Primary Health Centre RH Rural Hospital RCH II Reproductive and Child Health Programme-II RI Routine Immunization RNTCP Revised National Tuberculosis Control Programme SDH Sub-Divisional Hospital SHRC State Health Resource Centre SHSDP II State Health System Development Project-II SRHM State Rural Health Mission 6 EXECUTIVE SUMMARY The perspective plan for the NRHM aims to revamp the State health system to be more responsive, efficient and effective through a multi-pronged approach. The state plans to strengthen the provision of accessible, affordable, and quality health care to the rural population, especially the vulnerable section as envisaged in the NRHM and other Government Policy Documents. Primary focus would be to effectively operationalize the vast infrastructure available through hiring of doctors and paramedics from modern and AYUSH systems of medicine under NRHM. NRHM in J&K seeks to reduce Maternal Mortality Rate to 100 per 1,00,000 live births, Infant Mortality Rate to 30 per 1000 births and the Total Fertility Rate to 2.1 by the year 2011-2012 in line with the National Goals. Towards this direction, State plans to strengthen the existing health institutions through a number of interventions. 120 PHCs out of 375 will be made functional for 24x7 days services and 57 out of 85 CHCs will be upgraded as FRUS during 2009-10 as per the GOI Guidelines.. Besides, efforts will be continued to strengthen left out PHCs as 24X7 and CHCs as FRUs. This should be possible if our proposals in this regard are agreed to. In addition, it is proposed to strengthen 100 PHCs located in notified remote and difficult areas in an effort to make them effectively operational to provide health care services closer to the door steps of the people living in these areas. A special proposal to effectively operationalize these 100 PHCs in the remote and difficult areas of the State is to appoint on contract one each AYUSH and MBBS doctor