7th Common Review Mission National dissemination

Karnataka State 5th March 2013

Presenter on behalf of the Team : Dr.Raveesh R Mugali Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Mission Team

1. Dr. Manisha Malhotra, DC-MH 1. Dr. P.K.Srivastava, JD, NVBDCP 2. Dr. Raveesh R Mugali, UNICEF 2. Mr. M. K. Chowdhury, US, MoHFW 3. Dr. Raghu, Deputy Advisor,AYUSH 3. Dr. Shashikala, NHSRC 4. Dr. Balaji Naik. R, WHO-RNTCP 4. Dr. S. S. Das, MoHFW 5. Mr. Zacharia George, Planning Commission 5. Sh. Sanjeev Gupta, FMG 6. Dr. Nikhil Utture, Consultant NRHM, MoHFW, 6. Dr. Raghunath Prasad Saini, RCH 7. Ms. Chhaya Pachauli, Prayas CSO 7. Mr. Yogesh Kumar Singh, Planning Commission

2 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance :districts 7th CRM

Gulbarga

3 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Facilities visited Gulbarga District 1. District Hospital: Haveri 1. District Hospital: Gulbarga 2. Taluka hospital: Shiggoan, 2. Taluka Hospitals: Jewargi, Sedam 3. PHC 24*7: , Attigeri, 3. CHC: Mudhol, Malkhed, Gundagurti 4. Non FRU CHC: 4. PHC:Mandewal, Jeratgi, Aurad, Mahagaon, A mbalga, Madbool, Kadganchi 5. Ayush Hospital: Shiggoan 5. UHC: New Rahmat nagar, Ghazipura Urban 6. ANM/GNM training center PHC, Gullar Gali (Slum) 7. District Vaccine stores 6. SCs:Khanadal, Kattisangavi, Mandeval, Aurad 8. SCs:2 DH Neeralagi, Kuruba gonda, Attigeri , Sindigi, Madaki, Dhottargaon, Ranjol 9. Schools:4 FRU Attigeri and Tadas 7. ANM Training Centre PHC-9 10. Village: Neeralagi, Tadas, Kuruba 8. District Training Centre and R.F.W.T.C.Regional/State gonda,Ayush- 1Attigeri drug warehouse 9. Regional Drug Warehouse 11. MMU:SCs-11 Sheelavanta Somapura, Shiggoan District,regional AWC:4 10. Villages:Khanadal, Kattisangavi, Mahagaon, 12. Anganwadi center: Devagiri & ANM training Schools:4 Madaki, Neeloor, , Sindgicenters, Kansoor 13. SIHFW, Karnataka drug logistics and MMU-1 , Dhottargaon, Bennur K SIHFW warehouse Villages:13 11. Schools: Sindgi, Kadganchi 4 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Service Delivery

What sparks? What doesn’t spur?

• Infrastructure development • Inadequate provision of Staff (FRUs & 24*7 PHCs Tripled) Quarters • Utilization of Public health • Patient amenities are inadequate facilities has increased over 5 years • Privacy concerns • Wide range of services provided • A Number of deliveries reported • 108 ambulance service adequately in transit utilized • Diet provision for in-patients • AYUSH units co-located in most of • Coverage of all JSSK the facilities entitlements • MMU in PPP mode provides routine medical services to remote areas 5 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance

Functionalization of 24x7 PHC & FRUs, Karnataka

24* 7PHC FRU

1150 190 988 1001 1018 1018 1050 961 170 898 950 167 166 150 850 151 130 750 142 144 110 650 Tripled 550 107 90 389 450 70 Health infrastructure350 50 200754 2008 2009 2010 2011 2012 2013 33749 Karnataka State Haveri Gulbarga 2599824755

6887 5661 7844 989 1142 1397

Population/PHC Population/SC population/Bed 6 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Human Resources & Training

What Inspires? What stands betterment? • Doctors, Nurses, and ANM are • Compliance to key HR adequately trained esp, SBA recommendations trained nurses • Vacant GDMO and Nurses" • Majority of T.H. and D.H do have positions specialist doctors • Training needs assessment & Training plans • ASHAs are available, trained and • motivated Specialists at FRU’s/ TH (Gulbarga) • CPHN training of LHVs at SIHFW is • Placing Nutrition counselor good initiative and M.O. at NRCs

7 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance 8 Compliance to key HR Conditionalities

Article 371-J Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance RMNCH+A What needs correction? What is correct ? • Operationalization of Blood • Institutional deliveries – storage units and C-section facility increased to > 90% (70-75% in is needed in CHCs, THs( Gulbarga). pubic health facilities) • Safe abortion services below • Labor room nurses are SBA district level trained, • Orientation on processes for MDR • Partographs are being and quality of Reviews at facilities maintained and at District • Good visibility of Technical • Line listing of severely anemic protocols women • Emergency obstetric drugs were • 3 ANC checkup Gulbarga district (58 %) available in LR • Multiple referrals

9 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance

Inst deliveries trend change-Haveri MCH report 30000 Deliveries

25000 Home Deliveries Institution Deliveries Madilu Prasuthi 20000 kit arike FRUs 15000 24*7 JSSK PHC ASHA JSY

# of deliveries of # 10000 incentiv Thayi es Thayi bhagya 5000 bhagya Plus 0 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 10 A snapshot of RMNCH+A progress in Karnataka Maternal Mortality Ratio Child Mortality Rate

300 228 213 E-NMR NMR IMR U5MR 178 200 144 55 60 50 100 50 45 48 47 45 40 37 0 40 41 38 35 2001-03 2004-06 2007-09 2010-12 32 28 28 26 25 25 20 24 24 23 23 Child Sex Ratio (0-4) 20 20 20 19 22 20 20 955 0 960 951 946 946 950 942 2005 2006 2007 2008 2009 2010 2011 2012 940 930 934 925 930 Total Fertility Rate 920 2.5 910 2.2 2.1 2.1 2.0 2.0 2.0 2005 2006 2007 2008 2009 2010 2011 2012 1.9 1.9 2.0  Consistent improvement in health outcome  Achieved MDG 4 & 5 1.5  An estimated 1,600 maternal deaths and 41,800 under five deaths annually (Neo-natal deaths 26, 011, Infant 2005 2006 2007 2008 2009 2010 2011 201211 deaths-36,189) Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Percentage contribution of E-NMR to NMR, SRS 2012…highest in Karnataka

12 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance RMNCH+A Could be better Innovations & Improvements • 10- 12% mortality in SNCUs (Early • Prasuthi Araike Programme is popular NMR high in the state (87% of Karnataka has launched many State NMR) initiatives(PrasoothiAraike, Madilu, Th ayiBhagya and ThayiBhagya Plus) • Central oxygen supply which has dramatically increased the • Poor admissions in NRC due to lack institutional deliveries in Public Health facilities. of referrals. • ARSH: Services to adolescents in • IYCF practices needs improvement general OPD • Most women stayed 48 hrs after • Awareness about JSSK delivery at the FRUs entitlements, • Counseling provided by ICTC counselor or at Suraksha clinic . • Greater visibility of JSSK • WIFS initiated in schools • Delay in payment in few facilities • State Innovation- RoP at SNCU 13 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Immunization

Strengths Few Concerns • Immunization planned vs held > • Dropout rates 100% • MCV 2 Coverage-48% • Micro planning exists at every • Review of the immunization level programme using HMIS data is • Trained workforce & Increased difficult at all levels community mobilization-ASHA • Less cold space at state Vaccine store, Need of 1 WIC • Incentives for mobilization • Poor reviews at peripheral • Adequate cold chain space at level periphery, Avg population per • Immunization in private sector cold chain point:24000 • Due lists for tracking for 2 • Potential state for new vaccine years introduction 14 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance An example of Inverse care law

High number of measles outbreaks in Northern Karnataka MCV2 Coverage less than 20%

15 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Disease Control

RNTCP NLEP • Key RNTCP staff in position. • In the year 2012-13 ,3368 new • Programme reviewed regularly cases of leprosy were detected • State performance is moderate • Treatment success rates of 98% Areas to Improve.. • Shortage of Pediatric TB drugs and • Regular trainings are conducted Isoniazid 100 mg as per PIP • Low paediatric case notification • MCR & RCS available • High default rate • Endemic blocks are identified • Mandatory TB notification from private sector • Vacant positions to be filled up • Nikshay entry needs strengthening

16 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance

NVBDCP Malaria, Dengue & Chikungunya • Declining trend in cases Malaria and JE Filarial Elimination • Increasing trend of Dengue cases • Good efforts in Source reduction • State have 8 Filarial endemic • Passive & Active surveillance – ASHAs districts.3 qualified for stop are involved MDA planned TAS . • Entomological surveillance needs strengthening • Microfilaria rate has been Concerns reduced to less than 1% • Rapid diagnostic kits (RDTs) are out of • Gulbarga is under MDA and stock • needs to improve drug Urban malaria control • coverage during MDA A large number of negative slides examined to reach targets • practice of giving chloroquine as presumptive treatment 17 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance

NPCB IDSP • Eye operations done through a • Increasing in reporting (80% S network of public, private and P L). • Data used for planning NGO network • Regular programme review • Refractionists conducting • Weekly alerts generated and camps in schools. communicated Concerns • Less reporting from Private • Lack of opthalmologists in the sector Hyderabad-Karnataka districts • Ayush facilities not reporting under IDSP

National Programme for Prevention & Control of Cancer, Diabetes, CVD & Stroke (NPCDCS) only implemented in 5 districts 18 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance VHSNC ASHA • VHSNCs exist in all villages, active & • ASHAs are vibrant and active representative • Effective in mobilization • Regular meetings with minutes • Active involvement in NDCPs also • Optimum utilization of funds • Matching Grants for ASHA • Active in Monitoring of service delivery • Instances of irrational use of untied funds • Online system of ASHA payments e.g.bulk of fund spent on sarees Areas for improvement • Concerns • vacant ASHA positions • Coordination between the signatories • Regular supply of and needs improvement replenishment of ASHA drug kits • Capacity building and appropriate tools & HBNC kits and formats can be done • Establishment of ASHA restrooms • Timely disbursement and appropriate at health facilities utilisation of untied fund

19 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance

VHNDs Mainstreaming of AYUSH st • 1 Saturday of every month • Positives • As per the state’s guidelines – Co-located at the health • Service delivery is confined to facilities nutrition supplementation and – Trained in National Health counseling. Programmes • ANMs are not active in VHNDs – Managing sneha clinic • Immunization/ANC are PHC based • Concerns Areas for improvement: – Regular supply of AYUSH • Enhancing the role of VHNDs in medicines providing comprehensive MCH – Space and signage of and nutrition services AYUSH facilities • Reorientation of frontline workers – Role in Supportive on the significance of and supervision operationalization of VHNDs

20 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Medicine & Technology Observations Areas for improvement • Karnataka Drug Logistic and • Out of pocket expenditure Warehouse Society established in on drugs by patients 2003, and EDL in place. • Procurement and quality • Storage at health care assurance systems and indenting facilities weak. mechanisms are all in place. • Steps to strengthen • Drug availability in facilities good. diagnostics. Drug warehouses are being constructed

21 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Healthcare Financing • State share is more than 15%, • State spent >80% of NRHM allocation • Staff in position, funds transfer upto block level happening electronically and accounting satisfactory. • Expenditure and utilization is in line with expectations. • Audit processes could be strengthened and made more timely.

22 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Governance & Management • Programme Management Units well integrated with directorate, fully staffed and functional. • State and district health societies functional. • Public health cadre Has set up a committee((Dr.Haligi committee) for creation of public health cadre and is also encouraging doctors and programme officers to get public health management training. • NRHM Contractual posts appointments are decentralized

• Mechanisms for social audit such as Janvamsad, public meetings at villages and accountability measures for health needs to be put in place. • Supportive supervison:visits planned – but suboptimal implementation

23 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Best Practices & Innovations

• Maternal Health: Karnataka has launched many • Civil Works: Separate Engineering wing State initiatives under Dept of H&FW l(PrasoothiAraike, Madilu, ThayiBhagya and ThayiBhagya Plus) which has dramatically • increased the institutional deliveries in Public Immunogram model for improving Health facilities. immunization coverage and reducing dropouts and covering backlogs

• Matching Grants for ASHA: First of its kind in the • Karnataka Internet Assisted Diagnosis of Country, each ASHA is given an additional Retinopathy of Prematurity (KIDROP): It amount equal to the incentives earned by her is ’s first PPP in Infant Blindness ROP under NRHM, which will be funded by State Government. • RNTCP: Nutrition Support from the State • Innovations in Transfer & Postings :The to all TB patients Karnataka State Civil Services Act, 2011 • ASHA Online payment (Regulation of Transfer of Medical Officers & Other Staff) – Compulsory posting in rural areas. • Dialysis Units (In 1 taluka hospital of all 30 Districts a Dialysis Unit is established • Human Resource Management System (HRMS) with all facilities and treatment is provided free of cost) • Karnataka is the First state to Launch TMIS. 24 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Overall Areas of Improvement

• Primary health care service delivery with referral linkage- Quality primary care at SC and PHC to reduce the burden at FRU’s and district hospitals, – FRU’s to be made functional to reduce the burden on the tertiary hospitals – Sub centers potential to be fully explored, roles to be redefined-Non communicable diseases,BCC, • Key areas of quality improvement: EmOC Care,SNCU’s/NBSU’s/NBCC, NRC, RMNCH+A key interventions eg, PPIUCD,Safe abortion • User fees to be abolished -Free diagnostics and drugs • Implementation of public health cadre to be expedited. • GDMO’S in FRU’s and district hospitals Primary care vs specialist care • Ayush care with involvement in programmes and supportive supervison • Regular review of the programme using data -analysis -actions feedback –improvement (not limiting to reporting) • HMIS vs area wise reporting – HMIS data not adequately used for programme review, monitoring, formulation of plans and execution • Regulation of Private health sector

25 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance To conclude

• Karnataka is a very promising state • Visible changes brought in health systems • Contextualised Strategic interventions have the potential for a better health care model

Good is not good when better is possible. Thank you 26 27 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance KPMEA Karnataka Private medical establishment act

• Regulation of clinical establishments under KPME Act enacted. • Private health sector plays substantial role in healthcare provision • Private sector needs regulation to ensure quality and cost of care

• Even in rural district like Haveri almost Abstract35% bed strength is in private

• Total Alopathy.NH 95 DH 1x250 250 • Clinics- 51 TLH 6x100 600 • Dental -24 • Labs-38 CHC 4x30 120 • Ayush cLinic/NH: 353 CHC 1x50 50 • Total 561 • Bed strength:1006 24x7 PHC 37x6 222 PHC 30x6 180

42 private delivery points MH 1x30 30 8 JSY accredited Hospitals TOTAL 1452 28 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance Compliance to key HR Conditionalities Rational Deployment Partial Compliance-SNs. Majority of the LSAS/EmOC doctors not performing. Facility wise audit and State is doing facility wise reporting. Corrective action Service availability in health facilities uploaded on website but Partial Compliance. facility wise rating and action plan not yet uploaded. Performance measurement Yet to be fully complied with. system Baseline performance targets not uploaded on website. Baseline assessment of Partial Compliance-Action plan has been shared and the Competencies of SNs, process has been initiated for ANMs Filling up of vacancies of Not complied due to legal impediments regular posts of MOs, SNs etc.

29 Service delivery RMNCH+A Disease control HR and training Community process Inform & Knowledge Finance Medicine & technologyNUHM Governance RMNCH+A

Maternal and Infant death trend (absolute numbers: Haveri District) Infant Death Maternal Death

600 569 60 500 53 50 400 427 419 396 404 40 34 378 348 300 28 32 31 30 200 21 23120 100 13 14 10 0 0

30