3. Outline of presentation
•Introduction
•Planning process
•Strategy for Technical Assistance
•Framework for District Health Action Plan
•Critical areas for concerted action
•Component of District Health action plan
•Critical appraisal
3
4. Introduction
•DHAP is the Principle instrument for planning,
implementation and monitoring, formulated
through a participatory and bottom up planning
process
•Broad contour
•Situational analysis of the district
•Objectives and interventions
•Work plan
•Budgets
•M&E plan
References- Broad framework for preparation of district health action plans,
August 2006,NRHM 4
5. Introduction
•The DHAP will be guiding document for
implementation, monitoring & evaluation of NRHM
•It is envisaged that decentralized programme
management is likely to be more responsive to the
health care needs of local community
•Will be a step towards ultimate communitization - a
hallmark of NRHM
5
6. 6
Why emphasis on district
action plans?
•Mechanism to partner with community
•Planning based on local evidence and needs
•Area specific strategies to achieve NRHM goals
•Cost effective and practical solutions
•Move from budget based plans to outcome
oriented plans
•Requirement of GoI – no funds if no plans
7. 7
Why emphasis on
participatory planning
•Promote community ownership
•Greater ownership of health functionaries
•Harness benefits of community action
•Bring accountability of health functionaries to
community members
•Draw together elements that are determinants of
health
•Share resources and opportunities with partnering
departments – convergent action
8. 11
Planning Process…
V
GP GP GP GP
BLOCK BLOCK BLOCK
DIST DIST
STATE
Integrate
Integrate
Integrate
Integrate
VV VVVV V V V V V
PHC PHC PHC PHC
Integrat
9. The Planning Process
•Setting up of planning teams and committees at
various levels
•Village
•Gram Panchayat (SHC)
•PHC (Cluster level)
•CHC/Block level
•District level
•Orientation of planning team and contractual
engagement of professionals as per need has to be
the starting point for the planning process
12
10. The Planning Process
•Planning teams have to conduct
•Household surveys
•Help select ASHAS
•Organize training for community groups
•NGOs have a role in the entire planning process
14
11. The Planning Process
•Village Health Plans are likely to take time
•Therefore District, Block and Cluster level
consultation may have to form the basis for initial
District Plans ( ad-hoc and for a year)
•The perspective plans must be on the basis of
Village Health Plan but Block will be the key level
for development of decentralized plans
15
12. Strategy for Technical Assistance
•Development partners, department of community
medicine in medical colleges, NGOs with expertise
in this area
•10-15 member District Plan Appraisal Team under
the SHRC for appraisal of the Draft District Plan for
checking Quality, Standards, Normative criterions
before being sent to the State for approval
22
13. Strategy for Technical Assistance
•State Resource Centre would also finalize survey
formats and formats for preparation of plans at
various levels
•Finalize the criteria for prioritization and indication
of resources likely to be available for each Block and
convey these to the district
23
14. Essential requirements for preparation
for Village, Block, and District Health
Plans
• Constitution of planning team and committees at each
level
• Engagement of professionals on contract at State,
District and Block level urgently to meet planning needs
• Broad norms for planning activities & Space for
diversity and innovations
• Preparation of training modules for household survey,
Family Health Cards, Village Health Register,
• Mapping of non-governmental providers, and Health
facility surveys
• Survey of non-governmental health providers to assess
their possible role in the District Health Plan
24
15. Continued
•Organization of large scale activities like health
camps, Public hearings
•Involvement of Women’s groups and Community
based organizations in planning activity
•Release of untied grants to SHCs/ Gram Panchayats
to facilitate activities
•Recruitment and relevant training of ASHAs/ANMs
•Orientation of existing health department
functionaries on new ways of working
•Convergent local action along with other
departments 25
16. Framework for District Action Plan
• Assessing the present situation
• Resources – human power, logistics and supplies,
community resources and financial resources, Voluntary
sector health resources
• Access to services – including public and private services
and informal health care services
• Utilisation of services – including outcomes, continuity of
care; factors responsible for possible low utilization
• Quality of Care – including technical competence
• Community needs, perceptions and economic capacities,
PRI involvement in health
• Socio-epidemiological situation: Local morbidity profile,
adivasis, migrants, very remote hamlets
26
17. Critical areas for concerted action
• Functional facilities
• Improving human resources in rural areas
• Accountable health delivery
• Decentralization and Flexibility for local action
• Reducing maternal, child deaths and population stabilization
• Preventive and promotive health
• Disease Surveillance
• Hamlet to hospital linkage
• Health Information System
• Planning and monitoring
• Women empowerment, securing entitlements of SCs /STs /OBCs
• Convergence of various health programmes
• Chronic disease Burden
• Social security to poor to cover for ill health 27
18. Components of the District Health
Plan
•New interventions under NRHM
•RCH II
•Strengthening of Immunisation
•Disease Control / Surveillance Programmes such as
NVBDCP, RNTCP, NPCB, IDD, NLEP and IDSP
•Inter- sectoral convergence activities
•Nutrition, Safe Drinking Water, sanitation, female
literacy, women’s empowerment
30
19. Situational Analysis - District
profile
•Background characteristics
•Geographic area
•Number of blocks
•Size of villages
•Number of towns
•% urban population
•Birth and death rate
•Fertility rate
•Growth rate
•Sex ratio
•Population density
•Literacy
•% SC/ST population
•Health facilities
•Number and level (also
private)
•Functionality
•Human resources
•Health Indicators
•Common morbidities
•IMR, MMR, NNMR
•Nutritional indicators
•Infrastructure
•Safe drinking water
•Sanitation facility
•Primary schools 31
20. Situational Analysis - District
profile
•Coverage of ICDS programmes
•Availability of elected representatives of panchayat raj
institutions
•Presence of NGO’s
•Logistics
•Training
•BCC infrastructure
32
21. Situational Analysis –
Analysis of health indicators
Maternal Health
•% who availed complete
package of ANC services
•% of institutional, safe
deliveries
•Maternal mortality
•% of Maternal deaths
audited
Family planning
•Contraceptive use
•Unmet needs
•Implementation of
National FP insurance
scheme
Child health
•Immunization
•Breast feeding
•Malnutrition
•ARI and diarrhea
Interventions under NRHM
•ASHA
•JSY
•IPHS
•AYUSH
Performance of National
Health Programmes
Locally endemic diseases
22. Setting Objectives of the DHAP
•The inputs for this matrix will largely come from the
situational analysis conducted and the block-level
consultations should guide you in deciding what a
district can achieve in the given time frame
•Quantifiable objectives
•Force Field Analysis to determine the pros and cons
of achieving each of the objectives
•Interventions and Activities
35
24. Work-plan
District Level Planning Workshop
•To review and vet objectives of the DHAP
•To assess appropriateness and adequacy of
suggested strategic interventions/and activities to
meet the objectives of the DHAP
•Participants - District Collector , NRHM officials, PRI
representatives, District and block level officials from
dept. of health and other sectors, NGOs, private
providers
25. Work plan
•Model Work Plans – either month-wise or quarterly
for 1 and 2 year respectively
•Work Plan of Activities of each health component
Time of initiation of the activity
The tentative duration of implementation and
Persons/Agency responsible
•Overview of activities against which monitoring can be
undertaken
•Tracking the status of each of the defined activities -
Enhance accountability
27. Budget Allocation
•Equity based resource allocation
•Scoring based on socio-demographic indicators
•% of urban population
•% of SC/ST population
•% of skilled birth attendance
•Based on score – weightage allocation is given to
districts
•Identification of accountable person
•Administrative expenses should not exceed 6%
28. Resource Allocation for districts
42
Category Most vulnerable Vulnerable Least vulnerable
Score 7 and above 4-6 <4
Allocation
Weightage
1.3 1.1 Rest
30. Monitoring and Evaluation
• Input and Process indicators of each activity
• Performance evaluation mechanism will mostly rely on
baseline (RHS reports at district level, DLHS), concurrent, mid-
term and end-line surveys
• Monthly review meetings held at different levels of the health
system
• Community monitoring and reporting
• Assessing quality of services
44
31. Critical appraisal-1
VHSNC have been formed in 76% villages under
NRHM , but orientation for planning process and
capacity building of community leaders in village
level planning needs a deep look
Number of ASHAs (8.06 lakhs)1
but capacity
building was lacking (relevant training and
monitoring of their training)
Community empowerment –Though VHSNC is
lacking
At various level, proper utilisation Untied Funds
needs be looked into
1.Framework for preparation of annual programme Implementation plan of NRHM 2012-13 47
32. Critical appraisal-2
Appropriate situation analysis vital for DHAP which
is component lacking
District health action -plans still do not address the
local issues/requirements fully1
Though DHAP are prepared, they are not fully
incorporated into the state PIP
District allocation is made on population/ pro-rata
basis and often does not cater to the priorities of
the district and health facilities
1.Framework for preparation of annual programme Implementation plan of NRHM 2012-13 48
33. Critical appraisal-3
States still seem to have difficulties in preparing an
internally consistent PIP i.E. Where the situation
analysis, goals, strategies, activities, work plan, and
budget all tell the same story
Basis for setting targets could be more robust/
evidence based
49
34. Critical appraisal-4
•JSY has brought over a crore pregnant women into
public health facilities but the delivery load is
unevenly distributed across facilities. The fund
flows however are evenly spread across all the
facilities1
•With help of JSY though the institutional deliveries
had increased-but there is a concern about quality
of health care provided through it
Report of the Working Group on National Rural Health Mission (NRHM) for the Twelfth Five Year Plan (2012-2017)
50
35. Critical appraisal-5
Functional RKS against constituted facilities
Performance of RKS and pace of utilization of funds
and appropriate heads under which RKS funds are
being utilized is to be weighted
51
So far 8.06 lakhs ASHAs have been engaged across the country between community and health
system. 83% of them have been trained up to 5th Module and more than 75 % have been given drug kits. Following information should be provided on ASHAs in the PIP
Pro-rata basis –proportion
For example, if
institutional deliveries are targeted to increase from say 45% to 55%, most States do not
attempt to estimate the required increase in absolute number of institutional deliveries,
assess capacity of different facilities and hence the number of facilities which need to be
operationalised. Subsequently, targets for institutional deliveries would need to be set for
each facility and closely monitored
