Health planning at the district level

Shahkhund Primary Health Centre, a cluster of buildings in the Shahkhund block of Bihar’s Bhagalpur district, provides a strong case for at least two things. First, while Bihar’s rural public health system is not yet functioning optimally, there have been significant improvements in just a few years. And second, District Health Action Plans, an integral part of the decentralised strategy adopted by the National Rural Health Mission, have played a large part in making this happen.
Dr. Jayaprakash Singh, the Medical Officer in Charge (MOIC), has been at Shahkhund since 2001. He has seen the Primary Health Centre (PHC) transform from an under-resourced building with deferred maintenance, limited medications and few patients to a centre that serves the population by delivering babies, giving immunisations, controlling community-level diseases and providing a range of other services.

Dr. Jayaprakash and Mr. Madhukhant, the Block Health Manager of Shahkhund PHC, have been active participants in a series of workshops co-organised by the Public Health Resource Network and the National Health Systems Resource Centre with the support of ICICI Child Health. The workshops provide district-level functionaries with the tools, methods and knowledge required to undertake effective health planning.

District Health Action Planning is one of the primary emphases of India’s National Rural Health Mission (NRHM), the public health programme that aims to improve the quality of rural healthcare in the 18 states with the poorest health outcomes. At its most basic, health planning involves analysing the availability and quality of existing resources along with epidemiological patterns, and then determining what resources are required to improve district-level health outcomes.

Some of the major constraints in preparing these plans have been the lack of capacity at the block and district levels and the unavailability of resources and an institutional framework for comprehensive planning. ICICI Child Health, the Public Health Resource Network (PHRN) and the National Health Systems Resource Centre (NHSRC) devised the workshop series to address these gaps. The workshops taught district and block-level functionaries how to do a situational analysis to assess health needs and accurately estimate what infrastructure, human resources, drugs, supplies and other resources are needed. Just as importantly, the workshops taught the functionaries how to connect these needs to the process for making financial allocations to the district under the National Rural Health Mission. ICICI Child Health’s team also provided direct on-the-job support to the district and block level teams in Bhagalpur to prepare the district plan.

Previously, the preparation of Bihar’s health plans was done at the state level without any consultations in the 38 districts. Based on this health plan, the central government would make resources available to the state healthcare system. But even within a single state, districts may have strikingly varied needs; addressing malaria may be the most pressing need in one, while another may primarily need funds for vaccinating children. Consequently, Bihar’s health plans – as in most other states – had major gaps between what the state estimated was needed by the districts to provide effective healthcare and what the districts actually required. Moreover, there was little flexibility in spending the money, which meant that even if funds were available for certain expenses, they could not be used for other expenditures deemed necessary by districts.

Because of this disconnected planning, Bihar’s utilisation of funds was very low, despite availability of resources. Just two years ago, Bihar spent only 27 percent of the money that was allocated to it under the National Rural Health Mission, returning the rest at the end of the year. Though Bihar’s healthcare system is one of the worst in the country, year after year, money allotted to improve it could not be spent.

For this reason, the National Rural Health Mission zeroed in on including the districts in the planning process. According to the District Health Action Planning process, each district needs to make an assessment of its own resources, priorities and requirements in order to deliver a plan to the state. Based on the districts’ plans, a final state plan is prepared and delivered to the central government.

In addition to the workshops for block and district functionaries, ICICI Child Health facilitated workshops for the Auxiliary Nurse Midwives (ANMs) in Bhagalpur. ANMs play a key role in preparing the plans as they make regular visits to the sub-centres operating at the community level. In Shahkhund and other blocks, the ICICI Child Health-supported workshops taught ANMs how to use a template to assess the requirements of each of the block’s 23 sub-centres. To use the template, ANMs were taught to systematically collect information from the sub-centres on the number of infants in the community, the number of expectant mothers, the number of children from the ages of 1 to 5, and the number of people with various diseases. This information was then consolidated into block level requirements, ultimately working its way into district-level plans.

This has allowed the Primary Health Centres to function much more efficiently, says Dr. Jayaprakash, Shahkhund PHC’s Medical Officer in Charge. As a result of these detailed assessments, the PHC no longer has to wait until community members come to them to know what services they will have to provide. Based on the ANMs’ frequent reporting, the PHC knows already how many vaccines are likely to be required, or how many deliveries might take place, and they are able to estimate the resources they will require to provide this care.

Not only does Shahkhund PHC have a better idea of what resources are likely to be required, the funds for these resources now come automatically to their bank account. This frees them from constantly looking to the district and state for short-term, irregular approvals. Money is released quarterly and as long as 80 percent of the previously released tranche has been spent, the next tranche of funding is released to Shahkhund’s bank account within 24 hours of submitting utilisation certificates. Shahkhund PHC no longer has to depend on the district for funds to buy a water tank or to undertake general facility maintenance; these activities are already planned and budgeted for in the Annual Health Plan. Now instead of focusing on financial backlogs, the PHC can focus on providing healthcare. Similarly, the state government and district administrations do not have to concern themselves with approving ad hoc requests for funds and can focus instead on improving and monitoring programmes.

With new resources have come new patients. Out of the 182,000 people that Shahkhund PHC serves, 68,000 visited the PHC in the 2009-2010 fiscal year. To illustrate what a dramatic change this is, Dr. Jayaprakash observes that the same patient register that did not fill during the entire 2004-2005 fiscal year now fills up within a month.

The fact that the Primary Health Centres have such statistics readily available is itself a testament to the changes brought by the district health action planning process. Through the workshops, district and block managers learned to keep meticulous records and budgets to assist future planning. By building such high levels of capacity at the district level, the process of creating the district health plans has been as fruitful as the plans themselves.

This is particularly important because while state-level bureaucrats may be frequently transferred, the district functionaries are likely to stay in the district. Dr. P. Padmanaban, Advisor to the National Health Systems Resource Centre (NHSRC), has been struck by the high quality of human resources that now exists at the district level in Bihar. District health action planning relies a great deal on the capacity and motivation of individuals working at the block and district levels. And while this may mean that lack of technical knowledge and skills can constrain the planning process, the benefit is that once the capacity has been built at these levels, the process develops a momentum of its own. This, says Dr. Padmanaban, is an important difference between strengthening the capacity of the system and depending on outside agencies for constant support.

As a result of this work, all of Bihar’s 38 districts and 328 of its 534 blocks have prepared Health Action Plans for the coming year. Another achievement is that by March 31, 2010, Bihar’s health expenditure had reached Rs. 6 billion– significant progress for a state that until recently spent only Rs. 3 billion annually.

This year, the National Health Systems Resource Centre drew on the successful methodology and experience of preparing District Health Action Plans in Bihar to work with districts in Uttar Pradesh to prepare 71 district plans for the first time.

Certain gaps in the planning process remain. Communities, for example, have not yet fully participated in the process as mandated by National Rural Health Mission. The process of including community perspectives has begun, however, with the formation of Village Health and Sanitation Committees. These committees have their own bank accounts and access to untied funds that they can use to improve health and sanitation work in the villages. Community-level monitoring is the next step in the plan.