PROBLEMS & PROSPECTS FOR IMPROVING THE PUBLIC HEALTHCARE SERVICE DELIVERY

Substantial progress towards set objectives for the 10^th Plan aimed to provide essential primary healthcare services particularly to the under privilege and underserved segments along with devolution of responsibilities and funds for the healthcare to PRIs was established in the State. The State of Punjab devised a alternate healthcare delivery system by which it has been ensured to provide better healthcare services in the rural areas where percentage of population living in poverty is much higher.

 The details of the alternate healthcare delivery system is as under;

A)    ALTERNATE HEALTH DELIVERY SYSTEM TO PROVIDE BETTER HEALTHCARE SERVICES IN THE RURAL AREAS

In view of the 73^rd Amendment in the Constitution of India, the Department of Health & Family Welfare has devised an alternative health delivery system for the Subsidiary Health Centres i.e. Rural Dispensaries in the State of Punjab. The State Council of Ministers has approved that the health services in the 1310 Subsidiary Health Centres (SHCs) be provided through Zila Parishads (PRIs) by engaging doctors on service contract basis. With such arrangements, these institutions i.e. Rural Dispensaries will be more accountable to people through elected bodies of Zila Parishads, Panchayat Samities and Panchayats.

The Department has already issued necessary order in this regard on 8.12.2005. The salient features of the alternate health delivery mechanism to be followed are as under;

For all the 1310 SHCs/RDs, 1310 nos. of service providers (Doctors) will be engaged by ZPs on service contract basis by entering into a contract with individual doctor. The service provider (doctor) will be provided a lump sum package of Rs. 3.60 lakhs P.A. per SHC to be paid @ Rs. 30,000/- per month. The amount of remuneration package for all the Subsidiary Health Centres in the State will be provided as grant -in-aid to the Zila Parishads. He/she will also engage the services of a qualified Para-Medico to assist him/her for proper delivery of health services and implementation of National Programmes etc. in accordance with the service contract. Out of this package, the service provider (doctor) will also meet the day to day recurring expenses of electricity bills, water supply bills, sanitation and cleanliness arrangements other than the maintenance of the building, provision of furniture and equipment. Initially the service contract with the service provider (doctor) will be for a period of three year which may be extended further keeping in view the achievements/attainments of various benchmarks and satisfactory performance of the service provider (doctor). The maintenance of buildings of Subsidiary Health Centres will be carried out by the Zila Parishads and the requisite necessary basic equipments and furniture will also be provided by the Zila Parishads. The requisite medicines at the Subsidiary Health Centers will be supplied in kind @ Rs. 7,500/- per month which will be provided by Zila Parishads through Government funding.

BENEFITS OF ALTERNATE HEALTH DELIVERY SYSTEM:-

             Under this scheme the service providers (doctors) will be non-transferable.

             The regular doctors posted in Subsidiary Health Centres (Rural Dispensaries) will be withdrawn and they will be available for posting in PHCs, CHCs and Hospitals etc. Similarly manpower of Pharmacist etc. will be shifted to other Health Institutions. This will solve the problem of vacant posts of doctors and other para medical staff in PHCs, CHCs and Hospitals etc.

             It will eliminate absenteeism from Medical Institutions.

             These doctors will not provide health care only but also assist in implementation of several health programmes aimed at control of specific diseases as well as other priority areas such as Family Welfare and AIDS etc.

The State Government has taken up the reform and it is expected that in order to financially sustain the proposed system, the above alternate health delivery model may be funded by making allocations for the next five years under NRHM as per following details.

{Rs. In Crore}

B)    IMPROVEMENT OF CURATIVE HEALTHCARE SERVICES: 

Under the 450 crore World Bank aided Health Systems Project, all the 154 secondary level health institutions i.e. District Hospitals, Sub-Divisional Hospitals and Block level Community Health Centres have been revamped. 100 secondary level hospitals are located in the rural areas. In these hospitals new OPD/Indoor Blocks, Operation Theatres & Laboratory Facilities etc. have been added. The requisite modern medical and other equipments i.e. X~Ray Machines, Ultrasound Scanner, Cardiac Monitors, Defibrillators, Eye & ENT Equipment, Laparoscopes, Operation Tables, Autoclaves, Lab. Equipment, Laundry Units, Mortuary Refrigerators, Blood Bank Refrigerators etc. have been provided. 133 new additional ambulances and 17 surveillance vehicles have been added. Extensive training has been given to the service providers to enhance their clinical skills. As a result, as compared to base year of 1996, number of out patients has increased to 84%, no. of the surgeries to 945%, no. of X-rays to 760%, and, no. of lab. tests to 1488% in the year 2005. Due to providing of excellent diagnostic facilities at reasonable rates in the Govt. hospitals, the market rates of ECG, Ultrasound and X-ray have come down. The rates of ECG have come down from Rs.100/- to Rs.50/- , Ultrasound from Rs.450/- to Rs.150/- and X-ray from Rs.100/- to Rs.60/-. The World Bank in its final review has recorded that all the development objectives set for the project have either been met or exceeded.

The issue is regarding sustaining the project interventions specifically keeping in view updating the technology required for different medical interventions. 

C)    IMPLEMENTATION OF NATIONAL RURAL HEALTH MISSION (NRHM) IN THE STATE: 

National Rural Health Mission (NRHM) which has been launched by the Hon'ble Prime Minister on 12th April, 2005 aims at providing accessible, affordable, accountable and effective Health Care with emphasis on quality Primary Health Care. The goals of the Mission are:-

·                     Reduction in Infant Mortality Rate and Maternal Mortality Rate

·                     Universalize access to public health services for Women's Health, Child Health, water, hygiene, sanitation and nutrition

·                     Prevention and control of communicable and non communicable diseases, including locally endemic diseases

·                     Access to integrated Comprehensive Primary health Care

·                     Ensuring population stabilisation, gender and demographic balance

·                     Revitalize local health traditions and mainstreaming of AYUSH

·                     Promotion of healthy life styles 

IMPLEMENTATION IN PUNJAB 

The State Health Mission headed by Hon'ble Chief Minister and District Health Missions under the Co-Chairmanship of Deputy Commissioners and Chairpersons of the Zila Parishad as required under the NRHM have been constituted.

There are various disease control Societies like Punjab State TB Control Society, State Leprosy Society, State Blindness Control Society etc. at the State level. In addition, there is a Reproductive & Child Health (RCH) Society at the State level under NRHM. These Societies are to be integrated and merged into one State Health Society (SHS). The Governing Body for this State Health Society has been constituted under the Chairmanship of Chief Secretary, Punjab. Rules and Regulations as well as Memorandum of Association are under preparation and are near finalization. Similarly, at the district level District Health Societies for all the districts have been constituted and got registered (except in the newly created districts of Taran Tarn & Mohali). The Disease Control Societies at the district level are also to be merged into Integrated District Health Societies.

FINANCIAL STATUS OF NRHM 

During the Year 2005-06 against the total budget allocation of Rs. 9972.55 Lakhs, a total of Rs. 9109.68 Lakh were released by Govt. of India. Out of this release an expenditure of Rs. 6449.60 Lakh has been incurred during the year 2005-06 (71%). Similarly for the year 2006-07 Government of India has allocated an amount of Rs. 12844.46 Lakh.

THE KEY INTERVENTIONS BEING PROVIDED UNDER RCH AND INITIATIVES OTHER THAN RCH 

1.                  Essential Obstetric Care 

Under RCH Phase-II 50 PHCs/ Mini PHCs have been identified and are being strengthened for providing Essential Obstetric Care with 24 hours  delivery services. Inputs being provided for this to each of these Identified 50 PHC/ Mini PHCs are:-

·         Funds for provision of compact set of delivery room, minor O.T etc.

·         Power Generator Set

·         Two Staff Nurses on contract

·         One Female Doctor (Safe Motherhood consultant) on contract

·         P.H.C. drug kits

·         Telephone connections for referral services 

2.       Emergency Obstetric Care 

Emergency Obstetric Care is an important intervention for preventing Maternal Mortality and Morbidity. The complications of pregnancy such as Anaemia, Hemorrhage, Obstructed labour and sepsis are major cause of Maternal Mortality and Morbidity.

Under RCH-II in the year 2005-06, 25 CHCs have been identified and are being strengthened to provide Emergency Obstetric Care services. Inputs being provided to each of these 25 Identified CHCs are:-

·         One Obstetrician on contract

·         One Paediatrician on contract

·         Services of Anaesthetist on contract 

·         Four Staff Nurses on contract

·         A 'New Born Care' Corner

·         Blood storage Unit

·         CHC Drug Kits 

3.       Computerization upto Block Level 

Under RCH Phase-II Computer Systems alongwlth furniture have been supplied upto Block level to computerize the Health Department. Contractual recruitment of Computer Operators for the purpose is near completion.

4.       Implementation of PNDT Act 

Because of the multi pronged campaign involving strict enforcement of the PNDT Act and changing attitude towards the girl-child has improved the sex-ratio in Punjab State. According to the findings of the survey conducted in all the sub centres there were 817 girls to every 1000 males which shows a significant improvement over 2001 census ratio 798:1000.

5.       Janani Suraksha Yojana 

Under the Umbrella of National Rural Health Mission (NRHM) Govt. of India has launched Janani Suraksha Yojana (JSY). JSY provides comprehensive medical care during pregnancy, child birth and post-natal care. The main objective of JSY is to reduce maternal and infant mortality by focusing on increased Institutional deliveries and making available quality care during pregnancy, delivery and post delivery by linking delivery care to ante-natal check up and neo-natal care alongwith appropriate referral transport assistance in the Below Poverty Line (BPL) groups. Benefit is available upto two live births with a view to encourage small family norms.

(a)         Cash Assistance to the mother on the birth of a child in a Health Institution (Institutional delivery). Rs. 700/- is paid as assistance package to the mother in rural area and Rs. 600 in urban area.

(b)          Provision of Caesarean Section: Where Government Specialists are not available, assistance upto Rs. 1500/~ per case will be provided for hiring service of private experts to carry out the surgery either in a Government medical facility or in Private Hospital, Nursing home etc. 

INITIATIVES OTHER THAN RCH 

1.         Untied Funds at Sub Centre Level

Under NRHM Untied Funds of Rs. 10,000/- per Sub Centre have been provided to all the 2858 Sub Centres in the state to meet small day-to-day expenses of the Sub Centres. The money is kept in Bank Account jointly operated by the ANM and Sarpanch/ Member Panchayat.

2.         Upgrading of 51 CHCs (34+17) to Indian Public Health Standards (IPHS)

In order to provide Quality Care in these CHCs, IPHS have been prescribed to provide optimal expert care to the community and to achieve and maintain an acceptable standard of quality care.

For these upgradation of two CHCs from each district Govt. of India is to provide Rs. 40.00 Lakh for each CHC whereas the Government has released Rs. 6.80 crore to the state as 50% of the amount required to upgrade 34 CHCs to IPHS. Accordingly, 34 CHCs have been identified and the work of upgradation of these CHCs has been assigned to Punjab Health Systems Corporation and funds for the purpose have also been placed at its disposal. The estimates for the purpose have also been prepared and action has been initiated.

Govt. of India has further released an amount of Rs. 3.40 crore to upgrade 17 more CHCs @ Rs. 20.00 Lakh for each CHC on 29.4.2006. These 17 CHCs have also been identified and the work for the upgradation of these CHCs to IPHS is also being assigned to Punjab Health Systems Corporation.

3.         Corpus Grant for Hospital Management Societies / Rogi Kalyan Samitis (RKS) 

Hospital Management Societies / Rogi Kalyan Samitis are being constituted and registered at District Hospitals, Sub Divisional Hospital and CHCs to run the affairs of the concerned Institutions. A corpus grant of Rs. 5.00 Lakh per district hospital and Rs. 1.00 Lakh for other Institutions is being provided under the Scheme.

4.          Mobile Medical Units

              One fully equipped Mobile Medical Unit is being provided to each district to provide outreach medical and laboratory services in un-served and under served areas. Though the State is in the process of drawing up of a comprehensive Scheme of Mobile Medical Units but necessary guidelines from the Government of India are awaited