A Multi Sectoral Approach To Health (UNDP Aided) Project Management Unit (SWAJAL) Deptt. Of Rural Development, Govt. Of Uttar Pradesh
2 Structure Background Study and findings Action Plan
3 Background India is committed to achieve health for all by 2000 AD. A comparison of the situation existing in 1947 and 1997 reveals Year -> 1947 1997 Population 344 million 900 million Life expectancy 33 years 61 years Infant mortality 149 / 1000 74 / 1000 Under 5 mortality 246 / 1000 115 / 1000 Malaria 70 million cases with 2 million deaths every year 9 million cases with over 10,000 deaths
4 TB Small Pox Cholera Leprosy Year -> 1947 1997 2.5 million cases and 5 lakh deaths per year 70,000 deaths per year, 15% of all infant deaths More than a million deaths every year More than a million cases in 1947 12.7 million cases and 5 lakh deaths per year NIL - completely eliminated Almost eliminated but rising again. Gastroentritis rampant Decreasing rapidly
5 The financial outlay in the health and family welfare sector between the 1st plan and the 8th plan : (Rs. in Crores) 1st Plan (1951-56) Health- Family Welfare 65.20 00.10 3.33%of the total outlay 0.01% of the total 2nd Plan (1956-61) Health- Family Welfare 140.80 05.00 3.01%of the total outlay 0.11% of the total 3rd Plan (1961-66) Health- Family Welfare 225.90 24.90 2.6%of the total outlay 0.3% of the total Annual Plan (1966-69) Health- Family Welfare 140.20 70.40 2.1%of the total outlay 1.1% of the total
6 (Rs. In Crores) 4th Plan (1969-74) Health- Family Welfare 335.50 278.00 2.1%of the total outlay 1.8% of the total 5th Plan (1974-79) Health- Family Welfare 760.80 491.80 1.9%of the total outlay 1.2% of the total Annual Plan (1979-80) Health- Family Welfare 223.10 118.50 1.8%of the total outlay 1.0% of the total 6th Plan (1980-85) Health- Family Welfare 2025.00 1387.00 1.85%of the total outlay 1.27% of the total 7th Plan (1985-90) Health- Family Welfare 3688.60 3120.80 1.7%of the total outlay 1.4% of the total 8th Plan (1992-97) Health- Family Welfare 7525.90 6500.00 1.7%of the total outlay 1.5% of the total
7 Financial Outlay Rs. in Crores 8000 7000 6000 5000 4000 3000 2000 1000 0 1 2 3 4 5 6 7 8 PLAN Health Family Welfare
The outlay to each of the sectors during the last 3 plans within the overall umbrella of the social sector : (Rs. in Crores) Sector 6th Plan 7th Plan 8th Plan Total Education 2976.6 7685.5 19599.7 30261.8 Health 2025.0 3688.6 7575.9 13289.5 Family welfare 1387.0 3120.8 6500.0 11007.8 Housing and 2839.1 4836.2 10550.0 18225.3 Urban Dev. Other social services Rural Development 6688.7 15628.3 34786.3 57103.3 6996.8 15246.5 34425.5 56668.8 8
9 Rs. in Crores 35000 30000 25000 20000 15000 10000 5000 0 6th Plan 7th Plan 8th Plan Education Family welfare Other social services Health Housing and Urban dev. Rural Development
New initiatives during the 9th Plan The 9th Plan would emphasize greater involvement of local self Government institutions - Increasing role in ensuring planning, implementation and monitoring of health and family welfare services at the local level. Horizontal integration of vertical programmes like National Malaria Eradication Programme National Leprosy Eradication Programme National Tuberculosis Control Programme
11 National AIDS Control Programme National Blindness Control Programme Reproductive and Child Health Rural Sanitation and Drinking Water Rural Development Programme Programmes involving women empowerment and development of children
12 Inspite of significant achievements during the last 50 years, the human development indicators in the country are very poor Survival rates in India are comparable even today to the poorest nations of sub-saharan Africa Out of 25 million children born in the country every year, nearly two million die before reaching the age of 1 - most of these deaths are avoidable
13 Tuberculosis claims 5 lakh lives each year - main reason being acute poverty and deprivation. 12.7 million out of 16 million TB cases across the world are in India Water borne and water related diseases like diarrhoea, typhoid, cholera etc. account for 80% of India s health problems Every third person in the world suffering from Leprosy is an Indian
14 WHO has defined health not merely as absence of disease or disability but as a state of complete physical, mental and social well being
15 Significance of WHO definition It is erroneous to expect the conquest of disease and promotion of health through curative interventions by health professionals alone It should be possible to effectively prevent the tragic range of disease, disability, epidemics etc. by effective interventions which have a multi sectoral approach
16 Inspite of enormous amounts of investments the desired levels of outcomes not achieved The focus so far in the health programmes has been on single objective vertical technologically intensive sectoral programmes Integration of various schemes at the national, state, district and grass root level not seriously attempted Convergence has not been used as a internalised tool
Therefore there is a strong case for evolving an action programme for making the people/ community develop a scientific perspective on health and health care and render it more capable of making better choices at the individual level and at the level of planning. Such an action programme must lead towards full community participation in the evolution and implementation of health policies. 17
18 Health promotion could include the following : Interventions dealing with livelihood promotion for the rural and urban poor An employment guarantee programme Rural and urban sanitation Drinking water and improved shelter programme Effective implementation of PDS and ICDS programmes
Study and findings 19
A study was conducted in the two states of Tamil Nadu and Uttar Pradesh to understand the systems prevailing and the levels of implementation of the major health programmes 20
21 T. N. Findings The state has a relatively strong organisational structure. Senior posts are filled. Budgetary support exists for the programmes State Health Intelligence Bureau is active The state has achieved a great degree of success in bringing down leprosy cases. The number of leprosy cases have been brought down from 118 per 10,000 population to 7 per 10,000. This has been possible because of a strong commitment from the state Government and very effective implementation involving NGOs, other departments and a very focussed IEC campaign
22 The state has also achieved a large measure of success in bringing down the CBR, IMR and the TFR. Significant successes have been achieved in reducing maternal mortality. One of the reasons for the success of the RCH programme seems to be an effective involvement and integration with other developmental schemes at the district level The ICDS and the mid-day meal programmes have also been successfully internalised in the state
The same integrated approach does not seem to have been brought into practice in other national programmes like NTCP, NMEP, drinking water and sanitation etc. 23
24 U. P. Findings Studies about U.P. have shown that practically in all of the normally accepted important health indicators the State lags behind all India levels. A comparison of the all India indicators and South India comprising of all the four States shows the following (South India has been taken only as a reference for comparison) :
25 Indicator India U. P. South India Population, 1991 (million) 846 139 196 Life expectancy at birth 1990-92 years Female Male Death rate, age 0-4, 1991 (per 1,000) Female Male 59.4 59.0 27.5 25.6 54.6 56.8 38.4 33.2 64.0 60.9 17.8 18.9 Contd...
26 Indicator India U. P. South India Literacy rate, age 7+, 1991 (%) Female Male 39.0 64.0 25.0 56.0 49.0 68.0 Average per-capita consumer expenditure 1987-9 (Rs/ month at 1970-1 prices) Rural Urban 41.2 61.2 37.7 55.1 43.2 57.1 Head-count ratio, 1987-8 (%age of the population below poverty line) Rural Urban 45.0 37.0 48.0 42.0 41.0 42.0
27 The table below represents the situation prevailing in the state with respect to demographic and health indicators and in comparison to the states in Southern India Indicator U.P. South India Worse than UP Life expectancy at birth, 1990-2 (years) Female Male 54.6 56.8 64.0 60.9 MP, 53.5 MP, 54.1 Orissa 55.9 Other mortality related indicators CDR, 1992 (per 1,000) Under 5 mortality rate, 1992-93 12.8 141 8.4 82 MP, 12.9 None
28 Contd... Indicator Estimated MMR, 1982-6 (per 1,00,000 live births) Fertility Indicators Total fertility rate, 1991 CBR, 1990-92 Female-male ratio, 1991 Females per 1,000 males U.P. 931 5.1 35.8 879 South India Worse than UP 365 Rajasthan, 938 2.6 23.5 979 None None Haryana, 865
29 The table below shows the gender bias and female disadvantage in U.P. in comparison to South India. Indicator Females per 1000 males (1991) All ages Age 0-6 Gender bias in survival. Ratio of female to male death rates (1991) Age 0-4 Age 5-14 Age 15-34 U.P. 879 928 1.16 1.17 1.26 South India 979 962 0.94 0.97 0.84 Maternal mortality rate, per 100,000 live both (1982-86) 931 365 Gender gap in life expectancy (1990-92) female- male difference in years -2.2 +3.1
30 Indicator/ Region -> Share of total UP population 91(%) CMR, 1981 Male Female Female-Male ratio, 1991 Estimated Rural Birth rate, 1988-90 (per 1000) Literacy rate, age 7+, 91 (%) Male Female Incidence of rural poverty 1987-8 Index on real wages for male agricultural labourers, 89-92 Hima layan Western Central Eastern South -ern All regions South India 4.3 35.6 17.4 37.9 4.8 100.0 --- 106 110 170 145 164 158 154 144 166 147 160 146 91 104 955 841 855 923 846 879 979 32.4 39.7 37.8 37.4 37.1 38.0 25.3 43 76 27 55 28 55 21 55 24 58 25 56 49 68 8 26 36 43 50 35 30 --- 7.3 --- 3.5 --- 4.2 4.5
31 Keeping the situation in the State as a background a status study to assess the quality of implementation of health schemes in 2 districts of the State was conducted. The study revealed the following : a number of vacancies at the senior levels as well as the district levels even within the health programmes there was found to be lack of coordination between various functionaries. Where such coordination has been attempted like in the Pulse Polio Programme and the Leprosy Identification Survey limited success has been achieved
32 the organisation needs to be strengthened in terms of skills and human resource lack of direct communication with the community despite presence of village level functionaries inadequacy of training inputs at all levels there is a lack of interaction with other developmental departments the district officers like the DM are very often totally ignorant of health and health related programmes except for family planning and pulse polio and the blindness control programme to a limited extent. This has resulted in a lack of integration and convergence in the implementation of various health and health related programmes
Action Plan 33
34 The long term goal under the Action Plan would aim to develop models of health planning and community action so that a multi-sectoral approach to health and health interventions are understood, accepted and internalised at the district, sub-district, PHC and the community levels. An action plan to this end would need to be formulated regularly at the district level. The action plan will aim at developing a health intervention taking a holistic view of all existing developmental schemes presently being implemented with governmental and nongovernmental resources.
35 The action plan will attempt at convergence of all the schemes at the PHC, block and the village level through identified convergence mechanisms. The immediate output of the project would be : To draw up an annual district health plan to be formulated through the active involvement of all the functionaries involved in delivering developmental schemes. Drawing up of the action plan to be internalised. To train the district level functionaries in understanding the need for collecting of demographic profiles and health data, and to sensitise them to gathering important health information so that a suitably strong health information system is put in place in the district.
36 The health information system should contain elements which will ensure continuous surveillance of disease in the district through interacting with the community. In the course of the above, utilising the efforts and services of the community and the NGOs. Identifying and training of leaders of the community for implementing the convergence strategy at the village level so that the community is able to decide for itself its health needs and is also able to form village health committees to co-ordinate efforts with village and lower level functionaries so that effective implementation of the various schemes is ensured. To sanitize the village level governmental level functionaries for achieving the above goals.
37 To make convergence an internalised mechanism, the action plan would have to be drawn taking into account the following critical levels : National State District PHC/ Block Village and Community level
Convergence at National Level 38
39 Advocacy - the key principle Advocacy of MS approach at the centre - - while convergence in implementation is essential at the field levels, this is only possible when an integrated approach is advocated, formulated and insisted upon at the national level
40 Formation of a coordinating body which sets the guidelines for a holistic approach and prepares a basic minimum health program These illustrative guidelines emphasize to the states the need to approach the problem in a manner which ensures optimum results through convergence Assigning to an expert body the task of carrying out impact studies which relate to larger holistic health related achievements and which have a suitable mix of
Convergence at State Level 41
42 Identify the programmes which need to be implemented on priority and pooling of the funds to ensure that there is an agreement / intent to implement schemes which consciously emphasize the need for departmental coordination Concerned departments to draw up guidelines, fixed targets and outcomes and get issued a set of instructions under the signature of the Chief Secretary to all the district officials chartering the course of action for the whole year
43 Monthly monitoring of all the schemes by a senior officer of the State Clearance of the Chief Minister/ Cabinet be obtained for these set of strategies
Convergence at District Level 44
Key principle -- an attempt to present the health interventions and the various health schemes in a form which can be understood by non-medical officials including District Magistrate. This understanding would help the district machinery to draw up a district health plan 45
46 The main steps in district level planning are : To define demographic profile and health indices Collect health data from : -- primary sources -- secondary sources -- routine services -- surveillance mechanisms -- surveys
47 Produce health information and district health profile by analyzing and presentation of data. The district health profile report needs to be shared with not only the health staff down to health workers but also with Panchayats, NGOs and the mass media Developing a district health plan includes identification of high risk groups, estimation and coverage of present programme and infrastructure and choosing from alternatives Deciding on measurable outcomes - Programme evaluation
48 Operationalisation of the district plan will have the following steps : Creation of a resource team in the district which could be called as District Health Management Unit. This team could consist of a person experienced in IEC activities including organising campaigns health professionals having adequate knowledge of public health interventions a person experienced in understanding the requirements of the community with regard to problems of safe drinking water, sanitation etc. a person who could provide an interface with the other departments like RD, ICDS and Education, in the district. All these persons will be drawn from the district officials
49 Preliminary round of communication programmes to launch an awareness campaign Conducting participatory Health Survey to generate base-line data as well as to create publicity for the programme. This will inform and involve the community in the process of decision making by empowering them with the systematized knowledge that is necessary to make such a decision Training of functionaries at district / block / PHC / village levels
50 Organize a district level Health Mela where publicity and intense motivational campaigns to promote the health action plans are drawn up in the district After the period of Health Mela, depending on what is locally feasible, monitoring information and management systems should be operationalized. 3 to 6 months after the onset of the action plan phase of the programme a concurrent evaluation will help institute corrective measures and plan retraining of volunteers as well as publicize achievements at local levels The programme is to continue for atleast 2 years in the action phase.
51 Convergence at Block / PHC level
52 Key principle -- Translating district priorities into implementable action points The survey which have been mentioned as essential for the district plan has to be carried out under the leadership of the doctor incharge of the PHC The health functionaries at the the PHC level including doctors, as well as BDOs, ICDS functionaries need to be involved through out the drafting of the district health plan
53 The PHC level is best suited to organize the Health Mela The block has a list of persons below the poverty line, the list of hand pumps installed in its catchment and is in touch with the ICDS programme therefore any initiative which is taken by the PHC functionaries for focussed and intensive activity could be best done at this level.
Convergence at Village level 54
55 Key principle - Creating ownership by involving Village Health Committee (VHC) and optimizing output of village level functionaries by supplementing each others efforts. Sensitising the VHCs to their health needs by developing suitable imaginative health models through a process of group thinking, group responsibility and group action. A Village Action Plan will be drawn up at panchayat level Formation of VHC through a participatory process. The village level government functionaries such as ANM, anganwadi worker, Gram Vikas Adhikari, Gram Panchayat Adhikari, school teacher will act as a catalyst for facilitating the process of formation of VHC and assist it in its tasks
56 The core team of government functionaries will need to be trained in participatory approaches. they in turn will train the VHC in identifying area of convergence, implementing and monitoring of health and other development programmes. This will be initiated through Pehchan Melas wherein there functionaries recognize and know each other. Help of NGOs can be taken in organising these training programmes The core team will at first undertake rapport building exercise. They will inform the community of their objective of involving people in village health management.
57 The community will be involved to explore the present health conditions, behavioral practices, infrastructure and facilities available As a result of this creative investigation certain health related issues and problems would emerge. The core team will also assist the informal groups to analyze these problems and make them understand the linkages between behavior and health on the one hand and ongoing development programmes and village health on the other The VHC (7-12 members) will be formed as sub committee of the village panchayat. having representation of SC/ST and women
58 The committee will be assisted in seeking solutions to the existing health problems by the core team of government functionaries As behavior practices have a great impact on health situation, the VHC will tackle issues related to preventive health As a first step, the VHC will conduct a Healthy Home Survey. The findings of the survey will be discussed in a community wide meeting
59 The VHC will coordinate with the Village Development Officer and help the community to accept programmes like the Smokeless Chulha, Bio gas scheme and other such schemes which are being implemented by the Rural Development department. Similarly the VHC will coordinate with the Village Panchayat Adhikari in mobilizing families to construct / use house hold sanitary latrines, dovetail the JRY/ SRY resources for improvement of village drainage The school teacher along with the VHC will organize sanitation drives
60 Each VHC member will keep a record of the number of pregnant/ lactating women and children in the immunization/ supplementary nutrition target group and inform the ANM and anganwadi worker accordingly The ANM and the anganwadi worker will work in coordination with each other The anganwadi worker will also work in coordination with the school teacher The Gram Vikas Adhikari will coordinate with the ANM and anganwadi workers
61 Proposal for pilot testing In U.P. involvement of the community in social interventions in the areas of providing safe drinking water and reclamation of sodic land are being implemented successfully in many areas under the World Bank assisted projects. NGOs have been involved very effectively in these schemes in the last few years.
62 It is therefore proposed to pre test the multi sectoral approach in the following districts of U.P. : Pithoragarh (SWAJAL district in Hill region) Jhansi (SWAJAL district in Bundelkhand region) Rae-Bareli (Sodic land district in Central region)
Thank You 63