Integration in the Context of

Implementing the NRHM Mandate

NHSRC & CSMCH-JNU Collaborative Workshop

18th-19th August, 2008

Ritu Priya & T. Sundararaman

NHSRC
 In This Presentation:
I. Clarification of Terms : The Working Definitions we are adopting

II. Conceptualisation of the Scope and Potential Space for Integration under
NRHM, based on: a) the NRHM Framework, b) analysis of the state PIPs
and the discussions on them in the ministry, c) the Common Review
Mission reports, and d) observations in the field.

III. Brief analysis of the experience of Integration in the past for lessons and
warnings: The NTP, MPW scheme, IVBDCP, ICDS, ……

IV. Summarising the Challenges and a tentative proposal for moving towards
integration under NRHM.

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 CONVERGENCE IN PUBLIC HEALTH
Defining the Terms
CONVERGENCE = coming together of services and/or governance structures
or activities for a common set of health objectives.

INTEGRATION = intra-sectoral convergence, i.e. between various

components of the health care system. The convergence could be
organisational, administrative, and/or technical.

INTER-SECTORAL COORDINATION = functional linkages between the

health services and various other sectors that influence health status

COMPREHENSIVE HEALTH CARE = promotive, preventive and curative care

that addresses health status of populations from ‘womb to tomb’ . Includes
health services and other sectoral interventions. Services may or may not be
‘integrated’ at all levels.

PUBLIC-PRIVATE-PARTNERSHIPS = Convergence of Public and Private 3

sector services
 INTEGRATION: INTRA-SYSTEMIC CONVERGENCE

DEFINING THE BOUNDARIES FOR THE HEALTH CARE SYSTEM

 Within the public health services (excluding AYUSH)

 Within the public health services (including AYUSH)

 From home to hospital continuum of care including home

remedies and folk practices

 Within the whole health services sector:

• including all levels of care, from home to hospital,

• those of modern medicine and AYUSH, and
• public as well as private services
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 ARGUMENTS FOR INTEGRATION

 Administrative and Financial Efficiency and Cost-

Effectiveness

 Community and Patient Friendly as a One-Window

Service

 Epidemiological Rationality – Multi-causality and

social determinants of health, co-morbidities influence
outcomes of any specific programme

These considerations should guide setting of

boundaries of the system and sub-systems for
integration. 5
 Private
Public Healthcare Healthcare

Modern
Medicine Modern
Medicine

AYUSH
AYUSH

Local Health Traditions

The Health Care

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System
 INTEGRATION UNDER NRHM

NRHM PLAN COMPONENTS

Part A: RCH (maternal health + child health + family planning)

Part B: NRHM ADDITIONALITIES (Health Service System Strengthening

with Flexible funding for local planning, infrastructure, human
resources and governance restructuring)

Part C: Immunisation

Part D: Communicable Disease Control Programmes

Part E: Convergence (mainstreaming AYUSH and revitalising local

health traditions) as well as inter-sectoral coordination for health

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 Public Health Service
Delivery System
Tertiary

National Secondary
Systems
Health
Strengthening
Programs
[NRHM
[NRHM
‘B’ & ’E’]
A, C & D] Primary Level
Healthcare

Institutional Pyramid
Focus of Current
Integration
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Discourse
 Optional Approaches to Integration

Integrate Existing Communicable Disease Control

Programmes among themselves – within ‘C’ & ‘D’.

Integrate Existing Communicable Disease Control

Programmes among themselves and with the
Primary Health Care services – ‘C’ & ‘D’ with ‘A’;
‘B’ and ‘E’ to support.

Integrated (and Comprehensive) District Health

Planning based on local Epidemiological priorities
and Health care system context.
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 INTEGRATION UNDER NRHM contd.

The spaces that NRHM has provided for

integration:
•Departments of Health and Family Welfare in the MOHFW merged

•Integration of Vertical Disease Control Programmes – State and District

Societies merged into one State/District Health Society; A common NRHM
budget and the funds used through one common bank account.

•Mainstreaming AYUSH – AYUSH practitioner, paramedic and medicines

co-located with allopathic services at the PHC and CHC; ANM and ASHA
given a few AYUSH medicines, such as for anemia.

•Governance Structures – State/District Health Societies, Village Health

and Sanitation Committees, Hospital/Facility Planning & Monitoring
Committees ; Annual State PIPs / District Health Action Plans;

•Public-Private-Partnerships – To improve quality and access to services

of the underserved areas /sections.
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 INTEGRATION UNDER NRHM contd.

The spaces that NRHM has provided for

integration continued:
 
•An integrated HMIS for monitoring various activities

•The IPHS and the financial support to reach IPHS standards. Also
IPHS and service guarantees.

•HR development to meet facility needs as different from meeting

programme needs.

•Moves towards integrated skill development and training plans.

•Integrated BCC planning.

 
However each of these spaces are under-utilised and
sometimes not utilised or used in a way in which
vertical fragmentation is maintained. Documenting
how this happens and resisting it is the challenge. 11
 Integration between programmes/general health
services commonly envisaged in the states as:

Sharing of FAX machines, computers, etc.

Laboratory services / laboratory technicians be shared

Common bank account

Common management and monitoring structure - SPMU/DPMU

Untied funds to facilities strengthen them and support programmes

That is only as a greater form of administrative and financial

efficiency.

No element of technical/epidemiological rationality, people’s

needs and convenience.
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 NRHM as contested terrain….
 Between public provisioning of health services with public
financing versus private provisioning with public financing
(and public provisioning with part private financing eg user fees)!!!

 Between a vertical centralised health programme led

approach with systems back up versus decentralised
systems-led approach with increasing integration of
programmes.

 Between a sovereign self-reliant catch up with the world

based on the global best in knowledge and a
decentralised model of knowledge generation, versus
dependence on donors for technical assistance and funds
with a vertical model of knowledge diffusion. 13
 INTEGRATION UNDER NRHM
continued-

Two Public Health Paradigms

[Diverse Approaches to the Vertical Programmes and
General Health Services Interface within the NRHM]

The ‘Additionalities’ Approach: Parts ‘B’ and ‘E’ as

adjuncts to the vertical programmes

The ‘Health Systems Strengthening’ Approach: Part B as

major focus of the NRHM.

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 The NRHM Additionality Approach
 Parts A, C & D as primary focus: RCH-II, Immunization and
Disease control programmes: (Malaria, tuberculosis, Leprosy,
HIV)

All the above governed by international agreements

All the above vertical
All of which signed before NRHM
All of which dependent on externally funded technical assistance

PLUS
 Part B: NRHM additionalities, to attend to health systems issues that
limit effectiveness of the national health programmes.

PLUS:
 Health related sectors: very much of a token presence in
deference to political sensibilities
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 NRHM – as health systems
strengthening approach
 NRHM seeks to strengthen state health systems.
 Health programmes would increasingly get integrated
into it.
 Increasingly stand alone programmes would not be
necessary as “facilities and outreach programmes”
become fully functional, integrated, comprehensive.
 Also they would become unnecessary as some of the
current priorities are achieved and contribute less to
burden of disease eg leprosy, polio…
 This would facilitate decentralisation where centre’s
role would be limited to defining standards,
channelisation of finances and technical resources to
prevent uneven/inequitous development. Safeguard
equity and quality.
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 Fragmentation within NRHM Initiatives

NRHM setting up its own distinct, vertical administrative structures –

Processes for integrating these with the existing structures by 2012
essential

JSY fragmenting maternal health services by–

•SBA and institutional deliveries delinked
•ignoring community-based maternal services that atleast 20%
deliveries will require even by NRHM goals, and in practice many more.
•Once the programme/ incentives for institutional deliveries, the most
vulnerable will be left with no fall back at all.
•Since only 15% are expected to have any complications, subjecting
85% to unnecessary institutionalisation is wasteful and over-
medicalising.
•Dai huts/sub-centre deliveries with access to good emergency
transport and referral services possible under NRHM.
•incentive payent to ASHAs creating conflictual situations between the
AWW, ANM, ASHA in some states.
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 Contd.

Child health initiatives poorly linked to each

other.

HMIS, NHP data and disease surveillance

continue to be isolated from each other.

The Block Statistician still handles FP data

only!

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 Lessons from Past Experience
The National Tuberculosis Programme of 1962:
•classically planned to “sink or sail with the general health system”;

•based on a sound evidence base of epidemiological research,

•assessment of technology and delivery systems,

•patient’s disease related perceptions and treatment seeking behaviour,

•operational research.

Its success has been its functioning with horizontal integration at the district
and below, its in-built indicator-based monitoring system, and dealing with the
suffering of 30-40% of expected cases even with the low level of Public health
service functioning. The satisfaction that it did not distort the general health
services development.

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However:
•Its drug supply was irregular

•social support to the patients for long-term treatment was

missing.

•Its dependence on the training of medical officers to ensure

operationalisation of the well-planned programme lead to its
inability to change the dominant mindset, so the programme and
its integrated approach got marginalised.

•The RNTCP has corrected the first two, but not the dominant
technology-oriented mindset. Thereby TB treatment of the
majority is in the enlarging private sector and remains irrational.
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 NTP contd.

Negative Lessons:
1.Supplies and logistics are important operational issues
2.Social support is important in longterm treatment
3.Providers’ perspectives are important in implementation and have to be
factored into any planning process.
4.An institutional support and technical base as strong as the NTI and TRC
also could not garner adequate support for a disease that was the biggest
killer. A larger support for the approach has to be simultaneously garnered
for the programme to succeed. Foregrounding the social determinants of
health as well as the limits of technological interventions and developing
similar approaches to other health problems have to be simultaneous
activities to sustain it.

Positive Lessons:
1.A People-centred approach is most cost-effective and makes rational use
of technology.
2.A strong evidence- based rational programme acts as a restraint against
excessive distortion. 21
 Lessons contd.

The Multi-Purpose Worker Scheme

Meant to integrate the paramedical workers of various

vertical communicable disease control programmes.

MPW (male) lost the planners/adminstrators’ support due

to increased emphasis on the female MPW/ANM due to
the RCH programme and the ‘advice’ of funding agencies
to stop support to this cadre.

Then programmes had to re-invent primary level

paramedics, such as Roll back malaria programme’s
verticalised primary level ‘link workers’, DOTS providers 22
 Lessons to be Drawn from :

 The Integrated Vector Borne Disease Control Programme

 Integrated Disease Surveillance Programme

 Integration of the Leprosy Programme

 Integration of the Malaria Programme

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 Disease control:
Positive Impact of NRHM on malaria and
kala-azar control
 The control of malaria and Kala-azar received priority in areas
where these diseases are prevalent.
 Strengthened by the introduction of ASHA,
 Strengthening by filling up of MPW vacancies
 Strengthened by filling up medical officer vacancies
 Strengthened by improvement of laboratories .
 Work on the elimination of kala-azar accelerated.
 provision of free transport, free testing, free supply of drugs, and
free diet to patient attendants and payment of Rs. 50 per day for
the loss of wages.
 All the PHCs visited have admitted Kala-azar patients, tested the
patients and confirmed cases are treated as per the protocols.
 Adequate arrangement has been made for treatment, assured
drug supply and financial support for patients and one attendant.

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Janini Suraksha Yojana
 One of the public faces of NRHM
 “Conditional cash transfer” approach acts
as an incentive to bring a flood of new
users into public health systems.
 Forces attention on issues of access to
care, quality of care, on issues of human
resource availability and on issues of
infrastructure.
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Potential Impact of JSY on health
systems….
A.
Increase public private
partnerships.
Strengthen emergency transport
system..
Search for more opportunities for
conditional cash transfers to
achieve other programme goals.
Provide more inputs to public
facilities to improve quality of
care and increase 24*7 delivery
services, emergency obstetric
care etc.
Task shifting for achieving skills
needed (human resources for
maternal health),
B.
Using this as an opportunity for
achieving “fully functional health
facilities faster.”
Solve human resources for public
health by increasing nursing
education and multi-skilling in
major way;
Supplementing gaps with private
partnerships.
Strengthen traditional birth attendant
capacities with backup referral and
emergency transport
Strengthen emergency transport
system..
Strengthen newborn and child care in
PHCs and CHCs- providing
minimum norms and support for
the same.
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Example: Child Health:
Current:
 Begins with IMNCI.
 Immunisation:
 Vitamin A – in two
drives.
 Zinc for diarrhoea.
 SNCU in some hospitals.
 Skilled birth assistance in
some areas and “emonc”
in some facilities.
 BCC, malnutrition and
anemia missing..
 School health.. Here and
there, this and that..
Systems approach:
 Begin with protocols for ASHA(Home
based care for sick child), for
AWW(IMNCI), for subcenter(IMNCI), fro
PHC(SNCU-1) for CHC(SNCU-2) and for
DH(SNCU-3) and for school health
 Build in Nutrition Rehab. Centres
 Skill and support health care providers to
deliver these services
 Build up logistics to support it.
 Build up BCC and community mobilisation
to support it including VHND strategy>
 Monitor and support these services.
 Build up a district resource team and
management team to lead all of this:
(vitamin A and immunisation part of sub-center protocol,
zinc part of IMNCI)
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What drives vertical programmes…
 The central state- divide where the central funding determines
key programmes while state funding is limited to
salaries/establishment.
 The influence of donor agreements and their priorities.
 The structures and privileges that have developed over time
vested in vertical structures.
 An ideological perspective that public intervention should be
limited to few cost effective programmes for few pragmatic
internationally prioritized objectives- not try to provide
“everything for everyone” and to leave other private care to
market forces.
 An understanding/influence that prioritizes those investments in
public health that help develop markets- for products, for
services.., with a bias towards markets for corporate
structures..

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How do we articulate needs for integration:
without challenging the ideological perspective
 Monitoring: how monitoring of each programme depends on the other
and is more efficient and effective: How it can, in turn, be used to
promote better management and achieve convergence.
 Human Resource Development: all programmes need doctors , nurses,
health workers, managers: tendency to grab those available for vertical
priorities. But yet without a common plan for development of health
resources it is almost impossible to develop these resources- and
without synergy one cannot rationalize use.
 Human Resource Development: Skill development: not possible to
access in-service human resources for skill development without
synergy.
 Planning- especially district level and village level: why it is needed for
more effective vertical programmes , and in turn how its leads to
better allocation of resources.
 Infrastructure planning: Funds available for infrastructure from each
programme can be leveraged for all without sacrificing commitments to
funding agency.

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 ISSUES
 How do we look at non-communicable disease programme.. Can we
have national cancer control programme, national diabetes control
programme, national goiter control programme, national cardiovascular
disease control programme, national fluorosis control programme,
national mental health programme, national dental health programme,
national epilepsy control, national anti snake bite programme etc etc?

 Should we limit all the above programmes to only providing research

and resource inputs and insist on integration of all these?

 Current national programmes account for only 19% of morbidities-

what about the rest..

 Needs to be built into the concept of Fully Functional Health Facilities-

& Indian Public Health Standards

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 What could be an alternative perspective
on integration and convergence?
A. Health systems development is the main approach with
health programmes being interim measures.

B.District Health Systems development is needed because

it can lead towards:
 Decentralised governance
 Public participation in health governance.
 A citizen-responsive health system.
 A more effective and equitable health system.
 A more rational and cost-effective health care system.

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C. Programmes for special focus Communicable
Ds. and NCD to be designed for horizontal
integr. based on:

•Epidemiological priorities,
•people’s felt needs, and
•health service system context.

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 THE CHALLENGES

 Developing Human Resources to provide integrated

services gauranteed at each facility.

 An HMIS supportive of integrated monitoring.

 Integrated administrative and financial structures to

supervene over the present fragmented structure to allow
more need-based and cost-efective planning.

 Evolve planning processes conducive to integrated

health care.

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Thank You

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