Health sector reform initiatives in Gujarat Dr

Health sector reform initiatives in Gujarat Dr Amarjit Singh Principal Secretary (FW) & Commissioner Health, Medical Services & Medical Education Gujarat

Structural

Pre reform model Minister Health PS Health PD SACS Medical Education Constt. of health infrastructure dependence DGHS on R&B Sec FW

Integrated structure Minister Health PS Health Commissioner Health MD (NRHM) & PD SACS Rural health PIU Medical education Family welfare APD GSACS

Department of Health & Family Welfare: Govt. of Gujarat

Other Initiatives § § § § § DPCs AHAs Using ISM professionals Mentoring TCS HMIS Autonomy Capacity building Governance Communitisation

Clear goals

Our Goals • Reduce maternal and child mortality • Address adverse sex ratio • Stabilize population • Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia • Provide state of the art health and medical education relevant to local needs • Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services • Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals • Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Reducing Maternal and child mortality Chiranjeevi

MMR Over Time Source Time Period Urban Rural NFHS 1992 -93 (424) 397 448 NFHS - 2 1998 -99 (540) 267 619

Health care facilities available

Availability of OBGYs in CHCs Rural Popu OBGYs Reqd In place Gap Popu/gynec AP 55401067 167 73 94 7. 59 C'garh 16648056 118 26 92 6. 4 Gujarat 31740767 273 7 266 45. 5 M’ashtra 55777647 407 202 205 2. 7 MP 44380878 229 13 216 3. 41 Raj 43292813 325 109 216 3. 9 742490639 3910 1338 2010 India 5. 55

Bonus - saving neonates

SERVICE PACKAGE Service Normal delivery No. of cases Rate Per Case 85 800 Cost 68000 Complicated cases Eclampsia Forceps/vacuum/breech 1000 3 Episiotomy 1000 3000 800 Septicemia 2 3000 6000 Blood transfusion 3 1000 3000 Cesarean (7%) 7 5000 35000 Predelivery visit 100 10000 Investigation 100 50 5000 Sonography 30 150 4500 Dai 100 50 5000 Transport Grand total 100 20000 179500

Gynecologist involvement in Chiranjeevi # enlisted Total OBGY under District Specialists Chiranjeevi in the district scheme Total # of deliveries Performed Average delivery per Doctor BK 50 65 19407 299 Dahod 18 10 24038 2404 Kutch 47 18 11302 628 P'mahal 29 34 30509 897 SK 73 50 23818 476 Total 217 177 109074 616

Chiranjeevi Yojana Report June -08 Ending (20 Districts) Sr # District Name Compli Normal LSCS cated Total % LSCS # of Doctors Enrolled 1 Gandhinagar 2070 303 165 2538 11. 94 24 2 Mehsana 10905 953 772 12630 7. 55 42 3 Patan 11780 1089 357 13226 8. 23 36 4 Ahmedabad 20494 803 0 21297 3. 77 195 5 Kheda 3545 489 109 4143 11. 80 31 6 Anand 4691 882 17 5590 15. 78 32 7 Surendranagar 5676 335 80 6091 0. 00 27 8 Vadodara 5143 195 441 5779 3. 37 52 9 Bharuch 1856 264 176 2296 11. 50 21 10 Narmada 825 51 59 935 5. 45 6 11 Surat 2471 157 60 2688 5. 84 69 12 Navsari 2270 353 96 2719 12. 98 18

Chiranjeevi Yojana Report June -08 Ending (20 Districts) Sr # District Name Compli Normal LSCS cated Total % LSCS # of Doctors Enrolled 13 Valsad 2110 238 63 2411 9. 87 21 14 Ahwa-Dang 407 36 5 448 8. 04 4 15 Rajkot 3461 178 81 3720 4. 78 49 16 Jamnagar 1100 31 7 1138 2. 72 21 17 Bhavnagar 1824 206 38 2068 9. 96 10 18 Amreli 383 41 19 443 9. 26 14 19 Junagadh 973 157 40 1170 13. 42 13 20 Porbandar 703 188 16 907 20. 73 10 21 20 District Total 82687 6949 2601 92237 7. 53 695 22 5 District Total 93118 5465 10491 109074 5. 01 177 23 25 District Total 175805 12414 13092 201311 6. 17 872

Chiranjeevi State 2007 -08 & 2008 -09 14000 12727 12000 10846 10000 10507 9350 8554 8000 11628 11475 6865 11404 10687 8924 7540 7453 6387 6000 4000 2000 0 APR MAY JUN JUL 2007 -08 AUG SEP OCT NOV DEC 2008 -09 JAN FEB MAR

Outcome of Chiranjeevi Scheme: Mothers & New Born babies saved Total Deliveries under Chiranjeevi scheme 201311 Maternal Expect Mothers death ed saved reported Matern under al Chiranjeevi Death i scheme 805 39 766 Expected New born death reported under Chiranjeevi scheme New born saved 7650 829 6820 • Normal Deliveries: 175805 • C-Section: 12414 (6. 17%) • Complicated Deliveries: 13092 (6. 50%) • Private specialist enrolled: 872/2000

Institutional deliveries trend

Extended Chiranjeevi and Bal Sakha

Our Goals • Reduce maternal and child mortality • Address adverse sex ratio • Stabilize population • Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia • Provide state of the art health and medical education relevant to local needs • Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services • Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals • Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Mass Media Takes keen Interest

Political commitment on the floor of the house.

Sex ratio at birth as per CRS records

Name of the Talukas Kutch 877 930 920 Jamnagar 860 871 794 Kheda 830 904 878 State average: 870 (2006) 785 813 790 930 855 849 779 813 789 Mehsana 796 883 Visnagar 794 707 Petlad 815 807 Sujitra Surat 801 Anand Sex Ratio- 2006 826 Bagasara Sex Ratio- 2005 818 Kukavav Vadia Sex Ratio 2004 850 Amreli Name of the Districts Sex Ratio- 2006 Ahmedabad City 4 Districts showing deterioration in sex ratio Sex Ratio 2004 814 774 Kadi 854 843 Chansama 758 751 Rajkot 852 773 Upleta 860 811 Jetpur 897 767 Dhoraji 842 832 Surat City 786 781 Wadhvan 865 815

Our Goals • Reduce maternal and child mortality • Address adverse sex ratio • Stabilize population • Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia • Provide state of the art health and medical education relevant to local needs • Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services • Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals • Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Special Initiatives for NSV

Crude birth rate

Our Goals • Reduce maternal and child mortality • Address adverse sex ratio • Stabilize population • Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia • Provide state of the art health and medical education relevant to local needs • Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services • Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals • Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Effective Implementation of national health programmes in PPP – Working with IMA – Outsourcing CD 4 testing – MNGOs, SNGOs and FNGOs – Working with Rotary and Lions – GIA institutions – Outsourcing staff – Working with private OBGYs

Cure Rate Vs Case Detection Rate (3 Q 06/3 Q 07)

Cataract Surgical Rate (CSR) (2003 -08)

NLEP – Gujarat Endemicity as on May. 08 P. R. -0. 78 PM Dahod 1. 80 2. 36 Vadodara 1. 31 P. R. >5 3 -5 2 -3 1 -2 <1 Bharuch. Narmada 2. 80 1. 91 Surat 1. 50 Dang Navsari 3. 49 2. 58 Valsad 2. 81

70000 60000 57426 No. of Children provided Spectacles 50000 38424 40000 34582 40749 37341 30000 20000 10000 7961 7950 9252 11424 6420 0 1998 -99 1999 -00 2000 -01 2001 -02 2002 -03 2003 -04 2004 -05 2005 -06 2006 -07 2007 -08

Specialist services under school health programme INSTITUTE HEART KIDNEY CANCER ANGANWADI CENTERS 473 60 23 3703 484 159 4176 544 182 PRIMARY SCHOOL SECONDARY & HIGHER SECONDARY SCHOOL TOTAL

Route Map through Satellite based monitoring system Max. distance Desert Start

Curative services through MHUs Retrospective Status Satellite based Monitoring System implemented

Our Goals • Reduce maternal and child mortality • Address adverse sex ratio • Stabilize population • Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia • Provide state of the art health and medical education relevant to local needs • Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services • Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals • Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

PPP in ME • Medical colleges in PPP with Bombay hospital; United phosphorous; Narayan Rudalaya and Fortis • Setting up of PHFI Gujarat • Nursing colleges • Outsourcing staff; security; laundry • Outsourcing diagnostics • Outsourcing lab work

MOU s SIGNED VIBRANT GUJARAT

Our Goals • Reduce maternal and child mortality • Address adverse sex ratio • Stabilize population • Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia • Provide state of the art health and medical education relevant to local needs • Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services • Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals • Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

NOVEL INITIATIVES Institute of Kidney Diseases and Research Centre (IKDRC), U. N. Mehta Institute of Cardiology and Research Centre and Gujarat Cancer Research Institute are government funded institutes, administered by various private organizations. RKSs EMRI 108 To increase utility and performance of various government health facilities they are being run by private and local CBOs. Project Implementation Unit (PIU) a novel venture by Gujarat Government to undertake infrastructure development aggressively NABH/NABL HMIS

EMRI - 108

EMRI • EMRI is a non-profit organization based on the Public Private Partnership (PPP) model in Gujarat. • The service is currently available in parts of Gujarat through the toll free number 108. By August end 400 ambulances will serve the whole state. • The pre hospitalization emergency care provided by EMRI is free and the patient is admitted to a hospital of his or her choice. • More than 400 hospitals in the state collaborating with EMRI to stabilize the patient brought in, free of charge. • Massive capacity building • Setting up of EMS authority and EMS Act

Trauma care EMS act EMS authority Extensive planning for trauma care Trauma care services – – – A total of 93053 emergencies have been attended 39% 31613 trauma related 16% 13224 pregnancy related 291 pregnancies handled in the ambulance. 181 trauma care units already operational 4. 4 dispatches per ambulance daily All 400 to be operational by August 2008.

Running CHCs and PHCs in partnership with CBOs

PERFORMANCE INDICATORS Pre PPP Performance Name of Facility Community Health Center O. P. D. Post PPP Performance I. P. D. O. P. D. I. P. D. CHC Shamlaji Dist Sabarkantha 75 9 175 20 CHC Mota Pophalia Dist Baroda 65 10 69 20 CHC Malav Dist Panchmahal 35 3 149 23 Primary Health Center PHC Chansad Dist Baroda 1015 0 1155 14 PHC Dahej Dist Bharuch 1236 0 5461 134 239 5 290 10 PHC Matano Mad Dist Kutch

Better infrastructure with PIU

PROJECT IMPLEMENTATON UNIT GUJARAT Project Implementation Unit is setup for repairs, strengthening, retrofitting and new construction work of Healthcare Structures. High level expertise in hospital design & structural engineering aspects available on an outsourcing basis. Rigorous management information system with Gantt charts to ensure that the completion schedule are followed. The quality of the construction maintained through third party monitoring & supervision agency. Consultants / Experts are appointed for various services i. e. architectural planning, structural design, sanitary & plumbing design, electrical design, landscaping etc.

Repair, Strengthening, Retrofitting & Reconstruction (RSRR) Name of Work RSRR Works Number of Structures 1023 Details of Structures (Type) No of Structures GH CHC PHC Disp 4 50 121 7 SC SQ Total 300 541 1023 Cost 68. 30 Crores Present Status Completed

New Construction of Health Care & ICDS Facilities Name of Work New Construction Works ( Health Facilities + ICDS) Number of Structures 904 Total Structures CHC PHC AH Disp SC SQ TB Clinic 1 28 3 7 48 329 CDPO + CMSO Total Angan. 1 Cost 108. 62 Crores Present Status 76% of work completed 484 4 904

NABH/NABL ACCREDITATION • 1 ST PHASE (2007 -08) Food and drugs administration lab already accredited by NABL 8 District Hospitals (NABH) 1 Medical Colleges (NABH) 6 Medical Colleges (NABL) • 2 ND PHASE (2008 -10) 18 District Hospitals 5 Medical Colleges

PATIENT SATISFACTION

Making sense of data Enhanced patient care and effective use of resources with HMIS

Network Architecture - Health & Family Welfare Department Govt. of Gujarat • The screen shows the manner in which the networks for HMIS. • There is a central server which connects the local servers of each location to itself. • The firewall will restrict the anonymous access to the central site.

Hospital Management & Information System (HMIS) Patient Care Services • Registration Clinical Services Hospital Admin Ancillary Services • Clinical/EMR (Gynecology, Ophthalmic, Orthopedic, ENT, Gastro Medicine, General Medicine, Nephrology, Pediatric, Surgery, Urology, Skin etc…) • Hospital Admin • National Programs • Human Resource • Linen Management • Payroll • Equipment Maintenance • Financial Accounting • Resource Scheduling • Stores/Inventory • Special Camp & Training • Information Kiosk • Laboratory (Pathology, Microbiology, Bio Chemistry, Radiology) • Purchase • Bio Medical Waste • Nursing Care • Blood Bank • Complaints & Redresses • Application Security • Imaging • Transportation • Wards • Pharmacy • Billing • Patient Education • MIS Reports • EIS Reports

Management Information System - Data Flow Da ta Top Management Health Department Hospital Senior Management Users Of HMIS at District Hospital • State Level Monitoring • Expected Users : Health Minister, Commissioner, Secretary • All Programs like D & E, Malaria, etc… • Expected Users: Program Owner • Daily Dashboard • Expected Users: Hospital Superintendent • Disease Report, Death Report • Expected Users: Doctors, Nurses, Admin Staff

Blocks performing poorly

Institutional Deliveries – Vadodara Region Bharuch Vagra Narmada Nandod Dediapada Sagbara Vadodara Nasvadi Kawant Chota Udaipur Dahod Halol Panchmahal Ghoghamba

Institutional Deliveries – Panchmahal District

Institutional Deliveries in the PHCs in a Block in Panchmahal District

Our Goals • Reduce maternal and child mortality • Address adverse sex ratio • Stabilize population • Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia • Provide state of the art health and medical education relevant to local needs • Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services • Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals • Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Capacity building § § § Reservation of seats in PG seats Sri Chitra AMA TISS PHFI CORT SIDA UNICEF WHO fellowships Mentoring Awards for PP partners and our own staff

Our Goals • Reduce maternal and child mortality • Address adverse sex ratio • Stabilize population • Effectively implement National Health Programmes and address locally endemic diseases like leptospirosis, sickle cell anemia and thalesemia • Provide state of the art health and medical education relevant to local needs • Work with the citizens to make the health system more equitable, accessible, accountable, transparent, and cost-effective to enhance overall satisfaction with health services • Provide an environment in which the health teams blossom fully to lead a fulfilling life and effectively achieve the above goals • Develop public health capacities and systems, to effectively address determinants of good health such as potable water, sanitation, nutrition and healthy environment as well as to promote healthy life styles

Integrated disease surveillance Response PRIM HC REP SAMP RES begins Potential cases prevented CASES DAY

Issues • • • Malnutrition Neonatal health Unmet need for FW Sex ratio PPP initiatives Filling up of places Improving satisfaction with health care facilities Health infrastructure development corporation Capacity building

Department of Health Government of Gujarat