District level and PHC level Health Planning

Dr. Rizwan S A, M.D.,

DISTRICT HEALTH ACTION PLAN

Introduction

• Context – NRHM, RCH• District Health Mission

• Members of State and District Health Missions• District & Block level programme managers of line departments i.e., Health

and Family• Welfare, AYUSH, Women and Child Development including ICDSs and

water/sanitation• State Programme Management Unit and District Programme Management

Unit Staff• Members of PRIs and MNGOs/ FNGOs and civil society groups

• 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

• 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

What a District Plan ought to have

• Background• Planning Process• Priorities as per the background and planning process• Annual Plan for each of the Health Institutions• Community Action Plan• Financing of Health Care• Management Structure to deliver the programme• Partnerships for convergent action

• Capacity Building Plan• Human Resource Plan• Procurement and Logistics Plan• Non-governmental Partnerships• Community Monitoring Framework• Action Plan for Demand generation• Sector specific plan for maternal health, child health, adolescent

health, disease control, disease surveillance, family welfare

• District Health Plan reflects the convergence with wider determinants of health like• Drinking Water• Sanitation• Women Empowerment • Child Development• Adolescent School• Education • Female Literacy

The Planning Process

• DHP should be an aggregation of Village and the Block Health Plans• 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

• 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

• At Village, PHC and Block levels, • broadly representative committees would perform

• planning and on going monitoring

• A similar committee at District level • reviewing plans, based on drafting by the specialized district planning team

• Planning teams have to conduct • household surveys • help select ASHAs• organize training for community groups

• NGOs have a role in the entire planning process

Levels of planning and the key functionaries

• Village level Health and Sanitation Committee - responsible for the Village Health Plans• ASHA, the Aanganwadi, the Panchayat representative, the SHG

leader, the PTA/MTA Secretary and local CBO representative• Responsible for the household survey, the Village Health Register and

the Village Health Plan

Gram Panchayat Level Health Plans

• A group of villages or a single village• At the Sub Health Centre Level• The Gram Panchayat Pradhan, the ANM, the MPW, a few Village Health

& Sanitation Committee representatives • Organize activities like health camps• Overview and support for the household survey, preparation of Village Health Registers & Village Health Plan

Cluster level

• PHC/Additional PHC, 1-4 Clusters in a Block• Medical Officer in charge of PHC in close coordination with the

Pradhan of the Gram Panchayat covered in that Cluster. • The Cluster level would be responsible for over viewing the work of

Gram Panchyat/s and for organizing surveys and activities through the SHCs

Block/CHC level

• The Adhyakisha of the Block Panchayat Samiti, the BMO, BDO, NGO/CBO representative, head of the CHC level Rogi Kalyan Samiti will be key members• Social mobilization professionals and planning resource persons -

contracted • Finalize the Block Health Plans• Supervise household and health facility surveys• Organize public hearings and health camps

District Level

• The Zila Parishad Adhyaksha, the District Medical Officer, the District Magistrate - key functionaries• Draft plan will be formulated and presented for discussion to the

broader committee and finally streamlined • NGO representatives and a few professionals specially recruited to

meet planning and implementation needs• Responsible for household Surveys and Health facility surveys &

organization of health camps and public hearings • Every district health society would be assisted by a technical support

agency

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

• 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

Annual Work Plans & Perspective Plans

• The Perspective Plan - 7 year plan outlining the year wise resource and activity • The Annual Plan - based on resource availability and a prioritization

exercise• States should let districts know by October of the resources likely to be

available in the coming financial year• The District should disaggregate likely budget availability on the basis of

needs at village/cluster/block levels by November• The Village, Gram Panchayat, Cluster & Block Plans should come to

district based on a prioritization exercise

• The District Health Mission Society will recommend the Annual Work Plan and Budgets and the Perspective Plan to the State level Health Mission under the Chief Minister

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

• 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

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

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

Broad Outline of the Planning Process

• District health planning is viewed as an iterative and two-way process, where District planning teams provide overall planning framework and financial parameters, along with arranging training inputs• Village health plans → Block health plans → District health plan• Consultative process involving discussion of draft block plans with

Block health authorities, PRI representatives and block level NGOs• Consultative process, involving discussion of key block planning issues

with a few groups of selected village stakeholders

• Consolidation of block and district health plans• Technical appraisal of the Draft District Plan by District Plan Appraisal

Team• Presentation of the proposed District health plan to the District

health society and Zilla Parishad for final approval• Facilitating formation and capacity building of Village and Block

planning teams

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

Conducting Situational Analysis

• 1.Preparatory Phase• Data Collection• Household and Facility Survey• Secondary data available

• 2.Situational Analysis• Profile of the district in terms of

• Background Characteristics, • Health Facilities (Both Public And Private), • Functionality Of Health Facilities,• Logistics, • Coverage Of ICDS Programmes,• Availability of elected representatives of Panchayat Raj institutions and presence of

NGO’s, CBO• Helps to identify the constraints particularly in terms of size of villages, access

to villages etc.,

• 3.Public health facilities and functionality of facilities

• 4.The analysis• draw inferences of the extent to which the public health infrastructure is geared up to

provide health services and identify gaps

• 5.Logistics• Streamlined logistics systems can provide medicines, contraceptives, vaccines to service

providers in adequate quantity at right time and place and reduce wastage

• 6.Training Infrastructure• to equip providers with knowledge and skills for delivery of services in adherence with

standards of care

• 7.BCC Infrastructure• 8. Private Health Facilities

• These centres can be contracted for services under JSY• Surgical nursing homes for family planning

• 9.ICDS Programme• one of the critical programmes from the convergence viewpoints

• 10. Elected Representatives of PRIs• Making it community centric through the involvement of PRI’s

• 11. NGOs & CBOs• To organise service delivery activities• NRHM strongly advocates their involvement and ownership

• 12. Analysis of Key Health Indicators• overview of health and reproductive and child health status of the district using DLHS data

• 13. Maternal Health• an overview of the utilization pattern of maternal health services

• 14. Family Planning• 15. Child Health• 16. RNTCP, NVBDCP, NPCB, IDSP, NLEP & NIDDCP• 17. Locally endemic diseases in the district• 18. New interventions under NRHM

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

Block Level and Stakeholders Consultations

• Towards ensuring that the district health action plans (DHAPs) represent the voices on the ground, it is proposed to hold block level consultations in each block• Objectives

• To actively engage a wide range of stakeholders from the community in the planning process• To identify local issues and concerns as well as vulnerable group• Inter- sectoral convergence • To identify priorities at the grassroots and carve out roles and responsibilities

at the Panchayat for greater ownership

• Methodology and Format

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 – as per the format• Force Field Analysis to determine the pros and cons of achieving

each of the objectives• Interventions and Activities

The District Planning Workshop

• To review and vet objectives of the District Health Action Plan (DHAP)• To assess appropriateness and adequacy of suggested strategic

interventions and activities• Involve wider stake-holder and get a critical review and additional

inputs

Work Plan and Budget

• Work Plan of Activities• Activities have to be listed under the strategy and put in a matrix form with

• the time of initiation of the activity, • the tentative duration of implementation • completion should be specified • persons/agency responsible

• Scheduling of activities in a systematic way

Monitoring & Evaluation

• Including program management• Input, process and outcome indicators for every objective and

program included

Structure of the District Health Action Plans (DHAP)

• Background• geographic location, socio-demographic profile

• Situation Analysis• Coverage with preventive/promotive interventions• Income and Gender equity• Underserved population groups• Quality of services

• Process for Plan Development• describe processes undertaken• profile of participants

• Objectives• Matrix on key strategies and activities

• Work plan• how different activities will be conducted references to time frame and

responsible official

• Monitoring & Evaluation• Budget• Annexures

PHC Level Health Planning

Basics of micro-level planning

• Community Needs Assessment• Decentralized and multi level planning• Annual action plan• The planning process of management

• OBJECTIVES• ACTIVITIES• RESOURCES• Asking questions like who, when, where, how much, from where, to whom,

how, what etc.,

Because of its complex nature planning should be shared by all members of the team and by representatives of the community

Community Needs Assessment

• Actual needs of the people and not the needs as perceived by people at the top• Involvement of

• The community • NGOs• Community health volunteers• Women’s group• Panchayat

• Helps in setting priorities, identifying target groups, and developing realistic action plans

CNA Process

• Two types of teams (at HSC level)• Working team (under HWF)• Consultative team

• Working team – AWW, TBA,MSS, Link persons, youth leaders• Help in conducting household surveys and relevant info

• Consultative team – PRI members, teachers, religious leaders, NGOs, others

• Provide more information

Importance of CNA

• Provides a basis for determining health care needs of the community• Helps to prepare an action plan with plausible targets

Decentralized and multi level planning

• Initiated at the lowest spatial level by involving people• The core lies in enabling the HWF to take initiatives to organize

health care services • The decentralized planner is in a better position to plan for neglected

regions, sectors and sections of the community ensuring equity• ‘bottom-up’ approach

Multilevel planning

• Begins at the sub-centre level – crucial link• All the SC plans are combined at the PHC level with added

components • Finally sent to district level for formulating the district level action

plan

Sub-centre plan

• Prepared by ANM• A map of SC and its catchment area• Conducting household surveys• Group meetings with community reps for more info• Comparing this data with demographic calculations• Identifying HRGs• Estimation of workload and resource requirements

PHC Plan

• Compilation of SC plans plus additional activities specific to the PHC• Catchment area• Compile data from SCs and PHC• household surveys• Group meetings with community reps • Comparing this data with demographic calculations• Identifying HRGs• Prioritize the services• Determine workloads• Set targets• Match it with supplies and facilities• Prepare month wise activity plan for the year

Action Plan Forms

• SC plan prepared once a year in the beginning of the financial year by the ANM• PHC plan – two parts

• One concerning services provided in the PHC directly• Other relates to the services provided by the ANM

• FRU plan – services provided by them directly

Work plan

• With all the relevant information collected – work plan is prepared for own convenience• It enumerates the activities to be performed weekly

Step by step approach

• Step1; Looking at the situation• Step2; Recognizing important problems• Step3; Setting objectives• Step4; Reviewing obstacles & limitations• Step5; Scheduling activities

Step1; Looking at the situation

• Sources of information • Community representatives esp. leaders, teachers• Records

• Clinic records • OPD records• Registrations cards• Monthly reports• Stock legders

• Map of the area• Surveys

Type of information required

• Baseline information• No. of people and their distribution by age, sex • Principal occ.• Composition of family• Births, infant deaths, stillbirths, most common diseases, topography, water supply,

excreta disposal, food.

• Information on resources• Money, manpower, time, equipments, buildings

• Information about causes of a specific prob.,

• Information on the health work being done• Previous targets set and level achieved • Helps in identifying difficulties encountered

• Tabulating the information• Programme – target set – obstacles

• Analyzing the info• Sh be analyzed and digested • Recorded, standardized, communicated

Step2; Recognizing important problems

• What is a problem?• Obstacle existing between present situation and desired future state (gap in

what is and what sh be)

• Different people perceive problems differently• In solving a problem

• Clearly define the prob• All possible causes• Ways to rectify the causes

• Group problems• Diseases • Health service problems

• Lack of drugs, personnel, transport• Community problems

• Water, education, distance, poverty,

• Prioritize the several problems and the most important will be tackled first

How to determine priority?

• Does the problem• Affect large numbers• Cause high IMR• Affect maternal health• Affect children and youth• Cause chronic disability• Affect rural development• Cause concern to the whole community• Has an easy solution

Step 3; Setting Objectives

• An objective is defined as the intended result of a successful programme• Long term objectives – require several short term objectives which

are measurable• Short term objectives – operational targets• Objectives are usually time limited• An important use of setting objectives is Evaluation

Characteristics of useful objectives

• Relevant • Feasible• Observable• Measurable• Objectives can be set at different levels

• Ministry – broad• District level and village level – operational targets

Step4; Reviewing obstacles & limitations

• Things which prevent achievement of the objectives – • lack of

• People • Time• Money• Equipment• Information

• Geographical features – climate• Technical factors• Social factors

Analyze and classify the obstacles

• That can be removed• That can be modified or reduced • That cannot be removed or reduced• Look at the objectives again and change if necessary

Step5; Scheduling activities

• A set of activities to meet objectives is called a strategy• Consider alternate strategies• Balancing resources and needs• Choose the best course of action• Defining the chosen strategy• Writing an outline of the plan• Implementation

• Resources, organization, assignments

Thank you