District Health Action Plan

DR HARASHISH JINDAL JR

Contents

• Introduction• What is Programme Implementation Plan(PIP)?• What is District Health Action Plan(DHAP)?• Preparation of DHAP• Structure of DHAP• Components of DHAP• Budgeting Norms• References

Introduction

• Origin in National Rural Health Mission(NRHM) which was launched on 12th April 2005

• One of main core strategy was preparation and implementation of intersectoral district health action plan by district health mission including drinking water, sanitation, hygiene and nutrition.

What is a Programme Implementation Plan?

• Document prepared by states, which helps in identifying and quantifying their targets required for implementation of the programme for the proposed year.

• Finalized by National Programme Coordination Committee meeting for administrative approval .

• After approval, budgets are sanctioned, becomes an official document.

FLOW OF INFORMATION

What is a DHAP?

• Guiding document appraised and approved at State level for implementation, monitoring & evaluation of NRHM activities in the district.

• Makes decentralized programme management more responsive to the health care needs of local community.

• A step towards ultimate communitisation - a hallmark of

NRHM.

Need for DHAP

• Translation of a “new” health policy statement into a plan of action.

• Translation of a “master plan” such as a national plan into a district plan.

• Re-planning on the basis of an already existing plan, for the purpose of reviewing existing health problems and needs, and rendering services which are more effective and efficient.

• Meeting the necessary standards and achieving the set objectives.

• Economizing on available resources.• Ensuring coordinated effort and action.

Preparation of DHAP

• The District Health Mission has been entrusted with the responsibility of steering formulation and ensuring implementation of the plan. – headed by the Chairperson, Zila Parishad. – the District Collector as the Co-Chair– Chief Medical Officer as the Member Secretary.

• To support the District Health Mission, an integrated District Health Society (DHS) has been constituted.– to provide a platform where the three arms of governance – ZP, ULBs

and district health administration and district programme managers of NRHM sectors get together to decide on health issues of the district and delineate their mutual roles and responsibilities.

Bottom up approach

The Planning Process

• The NRHM had a seven year time frame (2005-2012).The Perspective Plan would be a 7 year plan outlining the year wise resource and activity needs of the district.

• The annual plan will be based on resource availability and a prioritization exercise.

• requires setting up of planning teams and committees at various levels –– Village level– Gram Panchayat (SC),– PHC (Cluster level),– CHC/Block level – District level.

• At Village, PHC and Block levels, broadly representative committees would perform both planning and ongoing monitoring functions.

ASHA, the Aanganwadi the Panchayat representative, the SHG leader and local CBO :responsible for the household survey, the Village Health Register and the Village Health Plan.

Plann

Steps of planning

Technical Assistance for DHAP

• State should harness all technical resources including development partners, department of community medicine in medical colleges, NGOs with expertise in this area etc.

• The State Health Resource Center (SHRC) would finalize survey formats and formats for preparation of plans at various levels.

• District Plan Appraisal Team :10-15 members, under the SHRC for appraisal of the Draft District Plan for checking Quality, Standards, normative criterions etc before it receives the formal approval.

Framework for DHAP

• Resources – health human power, logistics and supplies , community resources and financial resources, voluntary sector health resources.

• Access to services –public and private services and informal health care services, levels of integration of services within public health system.

• Utilisation of services –outcomes, continuity of care; factors responsible for possible low utilization of public health system

• Quality of Care –technical competence, interpersonal communication, client satisfaction, client participation in management, accountability and redressal mechanisms.

• Socio-epidemiological situation- local morbidity profile, major communicable diseases and transmission patterns, health needs of special social groups.

• Community needs, perceptions and economic capacities,

PRI involvement in health, existing community organizations and modes of involvement in health.

Framework for DHAP

Components of the District Health Plan

• It was envisaged that this plan would be a holistic plan but to facilitate fund release and for monitoring, the Plan may be divided into the following components:

a. Interventions under NRHM

b. RCH II

c. Strengthening of Immunisation

d. Disease Control / Surveillance Programmes such as NVBDCP , RNTCP, NPCB, IDD ,NLEP and IDSP

e. Intersectoral convergence activities including Nutrition, Safe Drinking Water etc

Components of DHAP

Situational Analysis

• Profile of the district in terms of its– background characteristics,– health facilities (both public and private), – functionality of health facilities,– logistics, – coverage of ICDS programmes,– availability of elected representatives of Panchayati Raj

institutions– presence of NGO’s & CBO’s

which helps to understand the district better and also to identify the constraints particularly in terms of size of villages, access to villages etc.

Interpretations

• Distribution of Villages by population size: Implications on how to organize services in outreach, assignment of villages to the additional ANMs and ASHA’s, addressing logistics issues for outreach services etc.

• Economic classification especially BPL distribution will help define estimations of JSY clients and also design interventions based on alternative health financing mechanisms.

• Literacy-male to female: Will help in designing of appropriate communication activities using more visuals than written material text

• Sex Ratio: Improve PNDT operationalization

Public health facilities and functionality of facilities

• Helps to know the different types of public health institutions in the district.

• How many institutions are actually functional in terms of availability of infrastructure and critical staff position.

Interpretations

• Percentage of facilities that are functional - analyze by categories • Based on the spatial distribution of facilities and availability of staff,

prioritize institutions for strengthening for providing services. • Issues of road connectivity with such institutions and the population

it caters. • Help identifying blocks in need of additional inputs for making

services available to the community or where demand side interventions such as ASHAs will be needed on priority.

• As staff transfers are frequent and non-availability of critical staff results in disruption in services, the analysis should identify such recurrent problems & discuss the probable solutions in block meetings.

Logistics

• Streamlined logistics systems helps provide medicines,

contraceptives, vaccines and other consumables to service providers in adequate quantity at right time and place and also help to reduce wastage.

Interpretations

• Address any out of stock situation: facilitate adequate buffer stock.

• Need for use of management techniques for logistics.

• The actions to be taken based on feedback reports of the vaccine quality.

• Poor storage of vaccines: Provision of proper cold chain equipment.

Training Infrastructure

• For capacity building of the functionaries, it is imperative to have good training infrastructure, competent staff members at the training institutions and necessary teaching aids.

• These institutions could be an ANM training centre, District

training team or centre or even the regional training outfits, Divisional Training centres etc.

• Private sector nursing training institutions should also be considered in this analysis.

BCC Infrastructure

• Assess availability of resources to undertake demand generation activities in the district??

• Hence for assessing BCC infrastructure in the district following information has to be collected.

• Identifies the areas of strengthening will be useful in planning for necessary inputs

Private Health Facilities and Type of Facilities

• With the government seeking public-private partnership through its programmes, it becomes more important.

• Depending on the motivation of the private provider to be a partner in the PPP mechanism, appropriate strategies and interventions could be planned on the basis of facilities and expertise of the institution.

ICDS Programme

• Critical programme from the convergence point of view.

• Complementary nature of job functions of ICDS worker at the village level with that of the ASHA/ANM strongly vouch for convergence of services and assures better accessibility to health care services.

• When district and block level consultation meetings are planned, it is important to ensure the presence of ICDS functionaries.

Elected Representatives of PRIs

• Sets out a process of communitization.

• Information from this matrix will – help to plan capacity development interventions for PRIs, – help the planning team to design local area -specific

interventions with PRI,• It is possible to expand some earmarked resources at the level

of PRIs.

NGO and CBO

• In the RCH programmes, mother and field NGOs are supported to organise service delivery activities in the district.

• The important role of non-governmental and community based organizations in community mobilization and ensuring their involvement is a proven testimony.

• NRHM strongly advocates their involvement and ownership, as essential pre-requisites for achieving the best results.

• Potiental for enhancing service access in under covered blocks/ sectors or even cluster of villages or working on the demand side.

Analysis of Key Health Indicators

• It brings out an overview of health and RCH of the district.• Idea of the utilization pattern among the different categories

and will provide necessary inputs as to what needs to be done to enhance services.

• Common diseases in the area, endemic pockets, and seasonality of diseases will be compiled.

• Identify blocks with poor or inadequate utilization and reasons there of .

• Summarize the reasons of poor utilization • Identify the reasons and make a note such as staff vacancies

Maternal Health

Examine the performance on the following indicators of • Percent of pregnant women who availed complete package of

ANC services• Percentage of institutional deliveries• Percentage of safe deliveries • Percentage of C-section deliveries• Percentage of Maternal deaths audited• Maternal mortality• Maternal death audit esp.verbal autopsies

Family Planning

• The unmet need for family planning will help us in estimating the potential users who need to be identified, counseled and provided services of their choice.

• While analyzing these indicators, also look into the reasons for discontinuation or non-use among current non-users and highlight the major findings.

• Any failures due to sterilization, deaths and major complications (requiring hospitalization) should be reviewed.

• If there are too many failures occurring in a particular block, then reasons in terms of skills of surgeons providing sterilization services and quality issues will have to be looked into and proper capacity building interventions will have to be planned.

RNTCP, NVBDCP, NPCB, IDSP, NLEP & NIDDCP

• Unlike RCH indicators, survey data on health is not available and hence will have to be compiled from district service statistics.

• The national monitoring of malaria and tuberculosis has confined to a few critical indicators that are compiled from the district level.

• Information on these indicators will have to be put together and along with it, other health Problems in the area will have to be stated block-wise

Locally endemic diseases in the district

• The information could be obtained from the hospital MIS or through surveys/ research. Any research reports available should also be reviewed.

• The distribution of the diseases as per blocks or cluster of villages (in cases of chemical contamination of water sources) should be mapped.

Interventions under NRHM

• Analyze the reasons for low performance such as in case of ASHAs, or disbursements for JSYs or registration of RKS etc.

• Propose appropriate interventions

Block Level and Stakeholders Consultations

Objectives:• To actively engage a wide range of stakeholders from the

community, including the panchayats, in the planning process • To identify local issues and concerns as well as vulnerable groups

and areas to reach consensus on feasible solutions/intervention strategies

• To take advantage of opportunities for inter sectoral convergence that exist at the block level in making the planning process more holistic in nature

• To identify priorities at the grassroots and carve out roles and responsibilities at the panchayat and block levels in design and implementation of DHAPs for greater ownership and needbased implementation of NRHM

Block Level and Stakeholders Consultations

• The timeframe is likely to be about a month and a half for the full process. The preparatory processes -a month. The next 15 days - actual consultations in each block of the district, set priorities and finalise outcome of the consultation for each block.

• A facilitator agency/NGO is needed to carry out the process.• Criteria for identifying the agency:– Involved with the development/social sector – Familiar with health issues, government programmes and

schemes and has an understanding of the field/community – Has staff (both men and women) with analysis and

documentation skills required to facilitate the process and to deliver in a timely manner

Step I(Problem identification)

• Involve MNGOs/FNGOs in the process of holding block level consultations

• Orient Gram panchayat representatives on the process and collection of village/ GP level information prior to the consultation

• Share and explain the use of the indicative checklist to collect GP level information.

• Service side information to be collected and gaps identified by the medical officers

• If possible, complement the information collected from the GPs with block/sub-centre level service data available at the facilities

Step II(Consolidate and analysis)

• Following the collection of GP level information, the facilitating agency/NGO to hold a meeting to validate the information (optional, to be held only if possible)

• Facilitating agency/NGO to consolidate the information collected and prepare note for circulation based on the indicative format at checklist 2.

• The panchayats and the service providers to undertake priority

setting during the consultation based on the consolidated picture presented by the facilitating agency/NGO

Setting Objectives

• The task of formulating DHAP objectives should take into account the state NRHM PIP and the Memorandum of Understanding between the state and the national government.

• Inputs from the situational analysis conducted and the block-level consultations guide in deciding what a district can achieve pragmatically, in the given time frame.

• SMART approach.

The District Planning Workshop

• Objective :– To review and set objectives of the DHAP;– To assess appropriateness and adequacy of suggested

strategic interventions/and activities to meet the objectives of the DHAP;

Attended by• District Collector– Chair for the workshop • CEO of the Zilla Parishad• NRHM Mission Director • Members of the District Mission • PRI representatives (10 at least 50 percent should be women) • District level officials from Health and Family Welfare

Departments • District level officials from Line departments i.e. WCD, Water

and Sanitation • Block Level Departmental Functionaries (especially from

WCD, Health and Water Sanitation) • NGOs/CBOs • Networks of the Private service providers

Work Plan

• A management tool to plot their various main and sub-activities at the beginning of the year.

• Once the activities have been planned, DPM would then need to see how they have been adhering to the planned programs, where the pitfalls are, the reasons why they lag behind the time schedule and the mid-course action required to correct them.

• two model Work Plans –– The month-wise plan is for one year plans– The quarterly work plan is for two year.

Work Plan

• Activities put in a matrix form wherein the time of initiation of the activity, the tentative duration of implementation and completion should be specified for each of them and more importantly, persons/agency responsible should be explicitly stated.

• Scheduling of activities in a systematic way .• All activities whether costed or not costed should be included

in the Workplan.• This matrix will facilitate in not only providing information on

when the activities have to be initiated and completed but can be effectively used for tracking the status of each of the defined activities along with monthly monitoring.

Monitoring & Evaluation

• State PIP document sets the input and process indicators and has decided on the frequency of monitoring.

• Performance evaluation mechanism will mostly rely on baseline, concurrent, mid-term and end-line surveys.

• Both internal and external as government and non-government agencies will be involved.

• Qualitative studies and community reporting will be done to supplement impact assessment studies.

• Evaluation system rely on District surveys.

Budgeting norms

Flow of Funds

NHM PIP Guidelines 2014-17(Background)

State Programme Implementation Plans (PIPs) will consist of the following five parts:– PART I: RMNCH + A (NRHM + RCH including immunization)

Flexipool ; – PART II: NUHM Flexipool; – PART III: Flexipool for Disease Control Programmes; – PART IV:Flexipool for non-communicable diseases including

injury and trauma; – PART V: Infrastructure Maintenance.

There will be a separate financial envelope tied to Parts I to IV within which every State will have the flexibility to allocate funds across different strategies/ activities in line with local conditions and within broad national priorities.

• At least 70% of funds should be allocated to districts. High priority districts to be allocated 30% more (vis-a-vis the population) funds.

• Tribal population / areas and vulnerable groups to receive special attention.

• Construction / upgrading of facilities should along with other parameters be determined by time to primary health care i.e. no more than 30 minutes of walking distance, and secondary care services including C-section and blood transfusion are available within two hours of any habitation, with an assured referral transport system connecting the two.

• In hard to reach areas, Mobile Medical Units (MMUs) should be used to provide primary healthcare services on a regular basis.

Resource Allocation

• Not more than 33%of total state resource envelope should be allocated for infrastructure in EAG states; for other states, the corresponding figure is 25%.

• Prioritise facilities with higher caseloads (deliveries, OPD/OPD services) for further development; all others should maintain or redeploy existing staff.

• Annual untied amount to be doubled for CHCs and District Hospitals; but this should be reallocated based on need/case loads.

Resource Allocation

• Up to 5% of state resource envelope may be allocated towards capacity building.

• No more than 5% of the total state resource envelope should be allocated for NGOs supporting service delivery; this may overlap with other activities such as capacity building.

• Programme management costs should not account for more than 5.5% of the total annual work plan; however in small states and union territories this may increase to no more than 10%.

Resource Allocation

• For technical assistance at the State and District level, up to 2% of the state annual work plan may be allocated.

• The cost of monitoring including MIS should be no more than 1% of total NHM funds.

• Up to 10% of the total NHM resource envelope may be used to fund innovations at the state level either – by establishing new centres and/or purchase of services

from private sector or– by way of meeting IPHS norms/ Quality of care standards

established as per national guidelines, greater allocation of untied funds as well as drugs and diagnostic services.

Resource Allocation

Untied funds for facilities: • The current annual allocation under NRHM per SC (Rs. 20,000) and per

PHC (Rs. 1.75 lakhs) would remain the same. • The annual untied fund amount per CHC: would be increased from the

current Rs. 2.5 lakhs to Rs. 5.0 lakhs, and for a DH it would be increased from the current Rs. 5 lakhs to Rs. 10 lakhs

• Untied funds, funds for RKS and untied maintenance facility level funds will be merged into a single untied grant to the facility.

• Funds admissible for different levels of facilities viz: SC, PHC, CHC, SDH, would be pooled according to the category of facility, at the district level and allocated to individual facilities based on utilization of funds,

case loads, range of services, keeping equity considerations in mind.

Financial Norms

• VHSNC: expenditures upto Rs 10,000 per VHSNC- but to flow according to utilisation and needs, with an increase of ceiling by 10% per year. The total funds for VHSNC in a district will be pooled.

• Community Process interventions, including Grievance redressal: – At the district and sub-district level upto 5% of the total

Community processes (VHSNCs, ASHA and grievance redressal budgets taken together).

– At the state level 2% of entire costs of VHSNCs, ASHA programme and Grievance redressal components taken together could be to resource center(s) programme management units.

Financial Norms

Financial Norms

• ASHA: – Support per ASHA upto Rs 15,000 per year, excluding

drugs and incentives. This is subject to a 5% increase per year.

– ASHA working in a population of 1000, (1000-2500 in urban areas) to earn at least Rs. 3000 per month, (in difficult areas where she serves populations of less than a 1000, additional incentives may be provided by states after notification).

– Incentives at national and state levels may be appropriately designed for a range of activities, based on the complexity of tasks undertaken by the ASHAs.

• MMU: The existing cap of five per district can be relaxed based on the area, difficult terrain, size of population, tribal and LWE areas, which are underserved. Norms for capital and operational expenditure will be suitable revised from time to time based on Consumer Price Index (CPI) and range of services provided.

• BCC: Funds will be provided based on specific plans while retaining the earlier norm of ceiling at Rs 10 per capita.

• Grant in aid to NGOs: Upto 5% of the NHM budget (of resource envelope of state) to be used to support NGOs for a range of activities

Financial Norms

• M&E: 1% of the NHM funds – of which resource 20% may be used at the national level, 30% at the State level and the rest at district level and below. 

• Technical Assistance: Upto 2% of the annual work plan - includes establishment and consultant costs in State Health System Research Centre and operational research and studies and knowledge partnerships at the state and district levels

• Capacity Building: Upto 5% of the resource envelope for costs of resource teams and institutions at all levels for capacity building.

• Innovation fund and support for disaster management: Upto 10% of the resource envelope would be used to fund innovations at the state level. Disaster response related interventions would be supported based on fund availability.

Financial Norms

• Planning & Mapping: Indicative unit costs are as following:– Rs.15 lac/city for planning/mapping of Metro cities– Rs.10 lac/city for planning/mapping of cities with 1 million plus

population– Rs.5 lac/city for planning/mapping of cities with 1- 10 lac

population– Rs. 2 lac/town for planning/mapping of towns with 50,000- 1 lac

population 

• Community Processes: Indicative unit costs are as following:– MAS/community groups: Rs.5000 per year per MAS– ASHA (urban): Approx. Rs.2000 pm per ASHA

Financial Norms (NUHM)

• Training & Capacity Building: Indicative unit costs are as following:– Orientation of Urban Local Bodies (ULB): Rs.5 lakhs for

metros, Rs.3 lakhs for million+ cities, Rs.1 lakh for other cities above 1 lakh and Rs.0.5 lakhs for smaller towns below 1 lakh

– Training of ANM/paramedical staff: Maximum Rs.5000 per ANM (for entire training package)

– Training of Medical Officers: Maximum Rs.10,000 per MO (for entire training package)

– Orientation of MAS: Orientation of MAS– Selection & Training of ASHA: Maximum Rs.10,000 per ASHA

(for entire training package)

Financial Norms (NUHM)

• Strengthening of Health Services: Indicative unit costs are as following:– Outreach services/camps/UHNDs: Maximum Rs.10,000 per

session/camp– Salary support for ANM/LHV: Maximum Rs.12,500 pm for ANM;

Maximum Rs.15,000 pm for LHV– Mobility support for ANM/LHV: Rs.500/m– Renovation/up-gradation of existing facility to UPHC: Rs.10 lakhs per

UPHC– Operating cost support for running UPHC (other than untied grants and

medicines & consumables): Rs.20 lakhs per year per UPHC– Untied grants to UPHC: Rs.2.50 lakhs per year per UPHC– Medicines & Consumables for UPHC: Rs.12.50 lakhs per year per

UPHC– Untied grants for UCHC: Rs.5 lakhs per year per hospital

Financial Norms (NUHM)

• DHAP is a guiding document appraised and approved at State level for implementation, monitoring & evaluation of NRHM activities in the district making decentralized programme management more responsive to the health care needs of local community.

• District Health Mission with support from District Health Society has been entrusted with the responsibility of steering formulation and ensuring implementation of the plan

• Bottoms up approach of village heath plan>SC Health plan> PHC Heath Action Plan> Block Health action plan>DHAP>PIP for planning and budgeting.

• Untied funds, funds for RKS and untied maintenance facility level funds will be merged into a single untied grant to the facility

Take Home Message

References

• Broad framework for preparation of district health action plans nrhm.Pdf

• www.nhm.Gov.In• NUHM PIP guidelines 2014-17• PIP overview 2014-17• Textbook of community medicine - sunder lal• Census2011.Nic