Transformation of Backward
Districts: Challenges & Broad
Strategies
Ministry Of Health & Family Welfare1
2
Health Care Challenges
Indicator Global Best Kerala India
MMR (SRS 2011-13) 3 (Greece) 61 167
U5MR (SRS 2015) 3 (Finland) 13 43
IMR (SRS 2016) 2 (Japan) 10 34
NMR 1 (Singapore) 6 25
TFR (SRS 2015) 1.8 2.3
OOPE 8% (France, Cuba) 62%
Most of the backward districts have poor indicators compared to national average 3
Health Care ChallengesIndicator (in %) (NFHS-4) Kerala India Jharkhand*
Mothers who had at least
4 ANC visits 90.2 51.2 30.3
Pregnant women
who are anaemic 22.6 50.3 62.6
Institutional births 100 79 62
Children 12-23 months
fully immunized 82.1 62 62
Children breastfed
within one hour of birth64.3 41.6 33.2
IndicatorTamil Nadu Jharkhand
Rural Urban Rural Urban
OOPE per child birth (Rs)– Public 325 655 1249 1857
*Jharkhand has the highest number of backward districts 4
FATE OF 1000 NEWBORNS DEATHS CUMULATIVE &
INDICATOR
First 1 week 19
1- 4 weeks 6 more 25- Neonatal Mortality Rate
1 – 12 months
(next 48 weeks)
12 more 25+12= 37*
Infant Mortality
1- 5 years
(next 48 months)
6 more 37+6= 43
Under 5 Mortality
~45% U5MR in first week ~33% of U5 MR In <72 hours~18% of U5MR in 24 hours
*Data for 2015 is used as only IMR data for 2016 is available: Current
IMR is 34
5
BROAD STRATEGIES: KEY EFFECTIVE INTERVENTIONS
Neonatal Care (First 28 days) (high institutional deliveries –major
opportunity) - NMR/ U5MR is 25/43.
Labour Room Practices -Quality of Intra partum and Immediate Post
partum care
Breastfeeding (1st vaccine)- 13% of IMR can be prevented by correct Bf
Improve access to FRUs - Comprehensive Emergency Obstetric & Neonatal
Care services including access to C-section and safe blood eg: 80%
shortfall in UP despite NHM flexibility
RMNCH+ A –Continuum of care approach
Improved implementation of Rashtriya Bal Swasthya Karyakram- Early
Screening referrals to DEIC & intervention
Anemia Management (oral and injectable Iron, diet)- NIPI implementation
Active case finding and treatment compliance, ensuring private sector
participation, H1 schedule register for TB- major threat 6
KEY EFFECTIVE INTERVENTIONS
Ensure Comprehensive Primary Health Care - 12 essential services,
universal health check-up & Screening for NCDs and management, improve
usage of public health facilities
Transform Sub- Health Centres as Health & Wellness Centres with mid-level
providers (Nurses & Ayurveda doctors trained in public health & primary care
through Bridge Course)
Pay Special attention to NPCDCS and Mental Health Programmes
Strengthen DHs as Multi-specialty care and site for trainings
Strengthen monitoring- Use Data for evidence based action (HMIS/MCTS/
CRS/ NFHS -4)
Implement Public Health Interventions across sectors
7
Ensure essential Drugs & Diagnostics (Often through PPP) -free of cost
in public health facilities (Drugs account for 72% of OOPE on OP care).
Focus on Patient centric care- safety and with dignity- mera aspatal
Focus on Quality Assurance and Kayakalp
Focus on Health Systems integrated approach for human resource
Pay maximum importance to quality recruitment
Use mobile technology- RCH/MCTS portal, Kilkari for health
transformation, health promotion
Forge partnerships with NGOs and Private sector
KEY EFFECTIVE INTERVENTIONS
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DMs oversee the design and implementation of District Health Action Plans
under the NHM. DPC and Zila Panchayat oversee health care delivery, monitor
the progress under the NHM, RSBY etc
Collector/ DM – Chairperson of the District Health Society and Rogi Kalyan
Samities of the District Hospitals- improve service quality
Use NHM flexibility- terms of engagement of HR-Align incentives (financial and
non-financial) to service providers to get desired behavior including quality of care,
design good contracts and monitor
Convergence & Co-ordination-Health outcomes depend on sectors outside core
health- nutrition, DWS, education, age at marriage, tobacco use, air pollution
Leadership, Improving Governance and Implementation
ROLES OF DISTRICT MAGISTRATES
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Roles of District Magistrates: Addressing Gender Inequalities
1981 1991 2001 2011
962945
927 918
Child Sex Ratio
Census (1981-2011)
• Pre-conception and Pre-natal
Diagnostic techniques (Prohibition of
Sex Selection) Act, 1994 - enacted in
1996 and further amended in 2003
• Prohibits sex selection before and after
conception and imposes penalty
• Implementation though DCs & DMs who
are District Appropriate Authorities
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Roles of District Magistrates in Immunization
• Identification of gaps and formulation of need based action plan - use of local
innovations
• Ensure enlisting of beneficiaries through head-count survey and its validation
• Ensure mapping of all high risk areas, remote hamlets, pockets of low
immunization coverage during micro-planning
• Facilitate rational deployment of ANMs as permanent measure & ensure
deployment to vacant sub-centres/urban areas during IMI
• Ensure proper social mobilization involving all stakeholders and sectors
• Lead from the front in dispelling myths/countering misinformation
• Ensure smooth and timely flow of allocated funds
• Ensure use of monitoring feedback for action
• Review the plan of integration of IMI sessions into Routine Imminization micro-
plans: critical activity for sustenance of gains11
Existing Output / process Possible Source
& Periodicity
Can be verified
by a survey
(quarterly)
NFHS once in
three years
% of ANC registered within 1st
trimester (within 12 weeks out of total
ANC registration (The indicator will
have impact on the gender equity as
well)
MCTS/RCH
portal -Monthly
Yes Yes
Proportion of registered pregnant
women receiving 4 more ANC
Checkups
HMIS - Monthly Yes Yes
% of High risk Pregnant women
delivered in the institution
MCTS/RCH
portal -Monthly
Yes Yes
Proposed Indicators: Antenatal Care
12
Existing Output / process Possible Source
& Periodicity
Can be verified
by a survey
(quarterly)
NFHS once in
three years
Proportion of institutional
deliveries (of reported deliveries)
HMIS -
Monthly
Yes Yes
Proportion of home deliveries
attended by SBA trained (of
reported deliveries)
HMIS -
Monthly
Yes Yes
Proposed Indicators: ATTENDED BIRTHS
13
Existing Output / process Possible Source
& Periodicity
Can be verified
by a survey
(quarterly)
NFHS once in
three years
Sex Ratio at birth CRS Yes Yes
Proposed Indicator: GENDER EQUALITY
14
Existing Output / process Possible Source
& Periodicity
Can be verified
by a survey
(quarterly)
NFHS once in
three years
Percentage of newborns
breastfed within one hour of
birth
HMIS-
Monthly
Yes Yes
Underweight children: % of
severely underweight children
under 5 years
ICDS
Adequate Supplementary
nutrition among children 6-9
months
ICDS
Proposed Indicators: HEALTH AND NUTRITION
CONVERGENCE
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Existing Output / process Possible Source &
Periodicity
Can be
verified by a
survey
(quarterly)
NFHS once in
three years
Percentage of
children fully
immunized (12-23
months)
MCTS/ RCH portal/
HMIS* - Quarterly
*If HMIS is using
indicator percentage of
children fully
immunized ( 9-11
months) may be used
Yes Yes (12-23
months)
Proposed Indicators: IMMUNIZATION
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Existing Output / process Possible Source &
Periodicity
Can be verified
by a survey
(quarterly)
NFHS once in
three years
Proportion of Primary Health Centers
as per IPHS normsHMIS & Quarterly No No
Infrastructure: Functional FRUs
against required number of FRUs (1
per 5,00,000 population in plain terrain
and 1 per 3,00,000 for hills)
HMIS & Quarterly No No
Availability of specialist services:
Proportion of specialist services
available at Districts hospitals against
IPHS norms.
HMIS & Quarterly
Proposed Indicators: Good Governance Indicators
17
Existing Output / process Possible Source &
Periodicity
Can be verified
by a survey
(quarterly)
NFHS once in
three years
Infant Mortality ( per 1000 live
births)
Civil Registration
System /Quarterly
Yes Yes
Percentage of deaths due to diarrhea
among deaths reported (1month- 5
years ) reported
HMIS & Quarterly
available
No No
Percentage of deaths due to
Pneumonia among total deaths (1
month- 5 years ) reported
HMIS & Quarterly
available
No No
Proposed Indicators: HEALTH OUTCOMES
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Existing Output / process Possible Source &
Periodicity
Can be
verified by a
survey
(quarterly)
NFHS once
in three
years
TB cases notified per 1,00,000
population
NIKSHAY- Quarterly
Treatment success rate among
notified TB patients
NIKSHAY- Quarterly
Proposed Indicators: HEALTH OUTCOMES
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‘Women & children are not
dying because of a disease we
cannot treat. They are dying
because societies have yet to
make the decision that their
lives are worth saving ……’
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FOR WOMEN, STILLBIRTHS, NEWBORNS, THE
TIME OF HIGHEST RISK IS THE SAME
1.2 million intrapartum
stillbirths
>1 million neonatal deaths
~113,000 maternal deaths
75% neonatal
deaths
Birth day
Birth is the time of greatest risk of
death and disability
Source: Lancet Every Newborn series,
paper2
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Stunting in early childhood associated with cognitive and educational deficits in
late adolescence, current programmes targeted to height/weight related
consequences of malnutrition, ECCE- stimulation very critical
Back to main presentation
100 billion neurons with 100 trillion connections develop during the first
1000 days of life
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Comparison of burden of TB, HIV and Malaria in India
Size of bubble proportionate to
deaths
Tuberculosis
HIV
Malaria
Disease DALY* Deaths
Malaria 287.18 562
HIV 520.21 67,000
TB 1258.37 4,80,000
*per 100,000 population
0
200
400
600
800
1000
1200
1400
1600
DA
LY
s p
er 1
00
,00
0 p
op
ula
tio
n
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INDIA: RISING NCD BURDENS2011
(in Millions)
2030 (in Millions)
Diabetes 61 101
Hypertension 130 240
Tobacco Deaths 1+ 2+
PPYLL Due to CVD Deaths
(35-64 Yrs)*
9.2 (2000) 17.9
*Potentially Productive Years of Life Lost (PPYLL) Due To
Cardiovascular Deaths Occurring in The Age Group of 35-64 Years
India stands to lose $4.58 trillion between 2012 and 2030 due to non-communicable
diseases- World Economic Forum Back to main presentation
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What risk factors drive the most death and disability combined?
GBD, 2015
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Sonbhadra (UP) Performance of Public Facilities – OPD(2016- 2017)
P
e
r
f
o
r
m
a
n
c
e
Facility Type CHC PHC SHC
Total no. of public
facilities6 29 173
No. reporting nil
performance 0 0 37
Max to Min Ratio 3 34 1485
Maximum 65534
(Dudhhi)
47914
(Kakrahi)
2969
(Nadhira)
Minimum 19916
(Babhani)
1419
(Bijpur)
2
(Chanchikala)
No. of facilities by
performance (FY
2016-17)
1 to 1200 0 0 1341201 to 6000 0 14 26001 to 12000 0 9 0> 12000 6 6 0
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Comprehensive Primary Health Care- Package of Services
1. Care in pregnancy and child-birth.
2. Neonatal and infant health care services
3. Childhood and adolescent health care services.
4. Family planning, Contraceptive services and Other Reproductive Health Care services
5. Management of Communicable diseases: National Health Programmes
6. General Out-patient care for acute simple illnesses and minor ailments
7. Screening and Management of Non-Communicable diseases
8. Screening and Basic management of Mental health ailments
9. Care for Common Ophthalmic and ENT problems
10. Basic Dental health care
11. Elderly and palliative health care services
12. Trauma Care (that can be managed at this level) and Emergency Medical services
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Under 5 Deaths: Causes
Source- Cause of Death Report, RGI (2010-13)
Estimated 10.8 lakh U5 deaths
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