Executive Summary Introduction Health is one of the most important sectors that demand a lot of attention in our country and Health as social infrastructure is not only significant but also a basic necessity of a human being. Perhaps for no other reason it is very well said that “Health is Wealth” A lot of involvement in policy development has happened after six decades of independence which is known to all. Many new policies and schemes have come up that takes heed of ‘overall health development, yet condition in many parts of India have not improved as much desired. Urban areas have had a positive impact more than that in rural arcas, The bimara states of India are still in the shadow areas and need a lot of attention even after implementation of ample numbers of schemes and programmes in the country across. ‘Maternal health and child health have always remained a matter of concern for every nation and its respeetive states. The focus has been moving to and fro of these two subjects since last two decades, The core indicators like immunization coverage, PNC/ANC registrations, delivery registrations, institutional deliveries, usc of family planning methods, and prevention from diseases play an important role in deciding health status of a country. There are many schemes and programmes implemented throughout India and also in different states that take heed of the above mentioned indicators, it has definitely benefitted some states but many of them are far behind what is actually expected. ‘Now the point that arises here is the policies that are implemented are not able to deliver 100% success or anything close to that, regardless of being inclusive and having the perfect solution. The striking question here is ‘where does the problem lie?’, ‘Is it policy making that has loopholes or Is it policy implementation’, ‘Is it policy making that is not sufficient to ‘fulfill the needs of all the states ar Is it the way of implementing the policy that makes all the difference in different states of the same country’, or ‘Is it the extra effort put by the state government to meet their needs and eliminate ail problems’. Are these health policies just an intervention or also innovation? The prime question is ‘what is the need of the hour, intervention or innovation"? Gujarat is a state in India which is moderately developed in terms of health and has indicators close to that of India. Hence it would be the best state to study as it is neither highly developed nor least developed so none of the sides would be overpowering. Moreover Gujarat's indicators fall close to that of India so its strength and issues can be related with that of India To understand Health Sector and its interventions in Gujarat it is important to first study the national/state health schemes implemented in the state. After doing the secondary study of ‘Devashree Roychowdhury, RPM - 0309" Page 1implementation of these, it is important to do primary survey so as to understand its working and implementation in actual. Primary survey is needed to analyze whether the write-up on paper is actually getting transformed into action or not. After deriving the inferences it is important to compare Gujarat and its performance with other states to find out its position and where it falls weak. Also one could figure out the loopholes in the state interventions and get ideas from other highly developed states to meet their own problems. In the end the discussion would be to decide whether the policies are just health sector interventions. or innovations which are truly needed at this hour. Furthermore recommendations would be given in order to meet the loopholes. Thus the aim of the dissertation is to study health sector interventions in the state of Gujarat. Ithas three objectives: + To have a broad understanding of health scenario in Gujarat; study of NRHM and its aspects and other PPP models aperatianal in the state like Chiranjeevi Yojana (C¥), Balsatha Yojana (BY) and EMRE 108 and also health insurance schemes like Rashtriya Swasthya Bima Yojana (RSB¥). * To undertake rapid appraisal of NRHM implementation and also Chiranjeevi Yojana in one of the districts of Gujarat based on the review of DLHS-3, district level household and facility survey Gujarat 2007-2008 by HPS Mumbai and MoHFW Delhi * To compare the state of Gujarat with other states of India in terms of health indicators such that its performance can be evaluated To get a hold on the subject it is important to go through a very comprehensive literature review so as to understand heath sector at a macro as well as micro level. Literature review ‘on health planning and health policies is also important to understand the aspect of policy formulation and implementation in health sector. Some of the books and papers on health disparity, health systems in India, health planning, maternal health and referral system were studied in order to understand different aspects of health. The inference that emerged out of literature review is that “In India it has been noticed with time that health conditions have been improving and one of the prime factors for it is maternal and infant mortality rate of the nation. Therefore in order to study health as a subject it is very essential to study policies and programmes that take care of MMR and IMR in India and work behind improving health infrastructure, Also from the literature review it has clearly emerged that it is very important to study the health system of a country in order to make a positive difference in health sector. To strengthen the health system of India it is important to recognize the policies implemented to upgrade it and thus to figure out the loopholes inside it and derive policy recommendations (for it. Ta achieve the above siatemenis it is necessary to have health planning which can eliminate all health disparities and attain health for all.”” ‘Devashree Roychowdhury, RPM - 0309 Page ILExecutive Summary HEALTH SECTOR INTERVENTIONS fN GUIARAT Health scenario in Gujarat: Government Policies and PPP Models The chapter is to study the health scenario in Gujarat which comprises of detail study of programmes and schemes implemented in the state like National Rural Health Mission (NRHM), Chiranjeevi Yojana (CY), Bulsakha Yojana (BY), Rashtriya Swasthya Bima ‘Yojana (RSBY), and E.M.R.I 108. Few of them are Central government schemes and few are state interventions. The chapter covers the reasons behind initiation of these schemes, its ‘objectives and goals and discusses analysis of indicators of Gujarat. Lastly the chapter also focuses on budget allocation in previous years and in 2011-12. This chapter can be concluded in this way that in order to understand the implementation of mentioned schemes and programmes in the state it is essential to carry out secondary as well as primary case studies in one of the districts of the state in detail. Analysing all the programmes and schemes of the state goes beyond the scope of thesis and has limitation of time frame. Moreover analysing few schemes would help in achieving a comprehensive study. NRHM (central goverument) and Chiranjeevi Yojana (state government) were selected as core subject matter as it is clear after this chapter that these ‘two schemes have lot of contribution in improving state health condition The study should be carried out in a district which is neither very highly developed nor least developed in health sector. If a highly developed district is studied, the strengths would be overpowering and vice versa. Therefore this criterion of studying moderately developed district should be adopted such that its strengths and weaknesses can be derived in a balanced manner. ‘State of Health in Baroda: Analysis of Health Indicators ‘The chapter is to understand the health scenario in Baroda. Baroda came out to be moderately developed districts in Gujarat on the basis of reviewing DLHS 4 and taking indicators like ANC registrations, immunization, family planning, and institutional deliveries. Baroda district is chosen which falls under moderately developed districts. This criterion was selected so that the conclusion derived after the analysis could be well related with other more and less developed districts of the state. Also the district should be developed enough such that data collection is feasible for a decent study and have enough loopholes to nurture ‘our perspective to plan a better strategy. After selection af Baroda district as the study area, the entire referral system was taken into consideration for understanding NRHM implementation in the district. Starting from the highest entity, the only district hospital Jammabai General Hospital’ in Baroda is studied. After that the nearest ‘Community Health Centre’ which is also a “First Referral Unie’ is reviewed which is ‘CHC Savli'. Later two ‘Primary Health Centres’, ‘PHC Bhadarva’ (working 24x?) and ‘PHC Vejpur’ (not working 24x7) is surveyed. These two PHCs come ‘Devashree Roychowdhury, RPM - 0309 Pageunder CHC Savli. Beyond these four SCs, two under each PHC is studied. SC Moxi and Natvarnagar come under PHC Bhadarva and SC Varsada and Inwada come under PHC Pejpur. The first 3 sections gave important information in the district like kind of facilities / infrastructure present in the district. District analysis was carried out from 2006-2009 under 3 ‘broad topies Maternal Health, Child Health and Family Planning in which all important subjects were covered like IMR, MMR, percentage of institutional deliveries, percentage of immunization coverage and others. This helped to understand the development / performance of the state in last four years. The broad inferences were that ANC registrations of Baroda District and its talukas have not improved much since 2006 till 2009, percentage of deliveries have remained steady and institutional detiveries have gone up tremendously. Deliveries in 24X7 PHCs have gone high highlighting towards the fact that people have become more aware about institutional deliveries and health facilities have improved in PHCs. Sex ratio has increased ta some extent which is a positive sign. IMR was low but since 2009 it has gone up. IMR is high in talukas namely Dabhoi, Savi, Padara, and Chota-Udaipur. MMR is high in talukas like Savli and Sinor and low in others. MMR and espectally IMR is a matter of concern for Baroda District. Full immunization coverage and use of all family planning methods have increased in the district from 2006 to 2009 which is positive. Also it was found that from April to December 2010, oud of the total deliveries conducted in the district, home deliveries are 12.9% and institutional 87.08%. Qut of institutional deliveries 36.7998 was in government institution and 63.2% was in private institution. Out of private institutions, 18.3493 was under Chiranjeevi Yojana and 81.65% under other private institutions. It shows that institutional deliveries have increased immensely and more people prefer private institutions over government institutions. Also it can be seen that people are ‘opting for other private institutions aver Chiranjeevi Yojana. This could be for the reason that Chiranjeevi Yojana is a scheme for BPL families. Review of Implementation of NRHM: Secondary Case Studies of Banaskantha and Surat Districts of Gujarat A Secondary study is important before going to the ficld and doing primary survey, for that reason secondary study of NRHM implementation is done in two districts namely ‘Banaskantha and Surat in this chapter. Banaskantha falls under least developed districts and ‘Surat falls under highly developed districts. These two districts were chasen to get a complete understanding of scenario in a developed and not-developed district. The criterion to review them was District Profile, condition of CHCs, PHCs, and SCs, functioning of ASHA, Community Perspective, Gram Panchayat and Quality of Services. It was found that Surat district had NRHM parameters more in place than Banaskantha district ‘Devashree Roychowdhury, RPM - 0309 Page IVExecutive Summary HEALTH SECTOR INTERVENTIONS IN GUIARAT ‘but in categories like condition of PHCs, functioning of ASHA, Gram Panchayat and Quality of Services Banaskantha performed well. In some of them listed above it was far much better than Surat. In Banaskantha focus should be improvement of CHCs and SCs (first referral unit) which is of utmost importance and demands attention. People should be made more aware of Health and Sanitation and about and different diseases and their precautionary measures. This would help improve the community perspective. Surat emerged as a developed district except some attention to be given in functioning of PHCs, functioning of ASHA and Gram Panchayat, Moreover both the districts had many common issues which are listed above. Understanding of Implementation of NRHM: A Primary Case Study of Baroda District ‘After getting hold over the schemes of the state and understanding circumstances of its implementation in two districts, primary study is important to understand its working in actual, its strengths and loopholes and in the end find ways to improve it by suggesting policy recommendations. This chapter comprises all of that. Primary survey in Jamnabai district hospital was carried by interviewing people working there since many years as data collection and photography was not allowed. Questionnaires for all Institutions in the referral system were made and also interview questions were developed for different category of people like ASHA workers, Sarpanch, patients, medical officers, chief district health officers, doctors, ANMs and FHWs. The rest of the components of the referral system except District Hospital like CHCs, SCs, and PHCs were thoroughly documented. The broad inferences are mentioned below. There are few issues common for all health institutions in the referral system in Baroda District like IPHS facility survey not carried out, need for manpower, important posts remain vacant and need for strong management information system. In district hospitals there is an issue of no ICU for infants or new born care corner. There is a need for proper utility facilities and medical record section in the hospital. Many important (posts are vacant and there is an urgent need for manpower. In Community Health Centres there are nat sufficient residential facilities for Health Workers. Blood storage facility is under construction. Some essential drugs / equipments are ‘missing in the institution. In Primary Health Centres cleanliness of PHC premises is an issue for nat being on regular basis, For Vejpur PHC another issue és that many doctors are not present in the PHC when ‘Devashree Reychowdhury, RPM - 0309 Page VExecutive Summary SECTOR INTERVENTIONS EN GUJARAT required, for the fact that there are very few or sometimes no patient throughout the day so they feel like wasting their time sitting in the PHC, that is why they prefer to remain outside in the field. In Sub Centres, building maintenance and cleanliness is @ major issue. In few of the SCs, some essential drugs and equipments are missing. Most of the SCs and aiso PHCs and CHCs in Baroda district are having population coverage beyond the existing norms. ASHA Workers face the problem of no fixed remuneration and no uniform. They are the crux af NRHM and should get a lot of encouragement. Training modules given to ASHA Workers are not comprehensive and need to be reformulated. Performance of Gujarat in Relation to Other States of Indi: Comparison of Basic Indicators After studying the schemes and policies at the micro level that is at the village level, block level and district level, it is important to evaluate its performance at state level in relation to others. This chapter deals with that. Af we talk about different states then southern states and Goa are highly developed than rest of the states in India. Conditions in UP, Bihar remain miserable. West Bengal, Sikkim, Maharashtra and Punjab are high in contraceptive prevalence rate, Data of other eastern states not available so drawing inference becomes difficult. Jammu & Kashmir has paid a lat of attention ta immunization coverage but deteriorated in other indicators. Though Gujarat has improved much from DLHS 2 to DLHS 3, it falls under the category of moderately developed districts which has most of the indicators same as that of India. it is not too good or too bad but there is definitely a long way to go. The study was carried out at different levels like state level, district level, block level, and village level to understand the impact of policies and its implementation at all levels. Conclusion is divided into two parts, first at the micro level covering study and inferences of District Hospital, CHCs, PHCs, SCs, ASHA Workers, and Patients and other at the macro level depending upon the secondary study done on Gujarat as a state and its performance with respect to other states in India, Furthermore, recommendations were given at these two levels and for NRHM and Chiranjeevi Yojana separately. Devashrce Roychowdhury, RPM - 0309 Page V1