Details for Reform Option "District Health Action Plans, Madhya Pradesh"
The Government of Madhya Pradesh (GoMP) decided it was impossible for the State to respond adequately to the health needs of its people with purely centralised planning because of its large geographical area. It proposed a policy of decentralised planning and implementation to make the health system more responsive and accountable.
The GoMP established the Rajiv Gandhi Mission (RGM) for Community Health in 2001, situated within the Department of Health and Family Welfare. The mission seeks to converge health-related resources and prioritize the needs of the poor in service delivery through strengthening and decentralizing authority to district decision-making structures.
In 2004, it developed planning guidelines and provided technical support to the districts to help them prepare Integrated District Health Action Plans. The planning process drew extensively upon the experience of District Action Planning in Guna district which had been undertaken in 1999 under the European Commission-supported Sector Investment Programme.
As well as the guidelines, the districts were told what funding to expect from both State and development partners so that they could plan realistically and not merely produce a wish list.
The planning guidelines included:
(iii) Restrictions tied to funding resources
(iv) Indicative guidelines pertaining to Component Management Protocols
(v) Common principals.
A core group of 4-6 people from government departments, private sector, Non Government Organisations (NGOs) and Community Based Organisations (CBOs) was formed in each district to facilitate the planning process.
The group was selected by the District Collector (DC) who was advised to only choose experienced people willing and committed to planning. A nodal officer was selected within the group to ensure coordination within the Core Team and between State and district.
A team of 7 external experts and a few departmental officials were also deputed to provide technical assistance to the districts because it was a new exercise. Each expert worked with 5 or 6 districts and was specifically told not to develop the plan herself/himself but to coordinate and facilitate the process.
Steps for developing a district plan:
(i) A two-day district level workshop to identify problems in the health sector and disseminate the purpose of having a district plan. Attended by all stakeholders including community leaders, representatives from Panchayat Raj Institutions (PRIs), line department and private sector, field level workers.
(ii) One-day workshops at block level for all stakeholders to discuss problems identified at district level and identify priorities and possible interventions to deal with these problems.
(iii) The core group worked on recommendations received from these workshops to finalize the list of interventions. The final plan was placed before the District Health Society for discussion and approval.
District plans which had a high level of attendance at workshop level were found to be of better quality. District level workshops were completed by July 2004.
Block level workshops completed by August 2004.
Plans sent to the State Directorate for approval by October 2004.
However, it was found there were significant gaps and lack of coordination in these first plans and major modifications were necessary. It was decided to review all the district plans the following year in the light of Reproductive Child Healthcare 2 (RCH2) and National Rural Health Mission (NRHM).
In April 2005, districts were given an improved set of specific guidelines, using the lessons learnt from the previous year’s exercise. They were again provided with a team of resource people to facilitate the planning work, with special regard to RCH2 and NRHM. Revised plans were finished by August 2005.
These District Plans were then appraised at State level before disbursement of funds and each plan was discussed with three different evaluation committees headed by the Commissioner for Health, the Commissioner/Director of the Information Education Communication (IEC) Bureau and the Mission Director.
Following this process, plans were approved and funds made available to the District Health Societies.
Local representatives of development partners provided technical assistance in the development of planning guidelines and facilitated the district core teams in developing their plan documents.
Four Area Health Managers (AHMs) at Regional Headquarters have been made responsible for ensuring coordination between the State and the districts. Since October 2005, they have observed the following:
(i) Micro planning of each activity under the District Plans in most districts has been completed and activities have started.
(ii) The Chief Medical & Health Officer (CM&HO) and DCs feel more accountable following the planning process.
(iii) There is more coordination between the CM&HOs and DCs who are more willing to work together to achieve implementation of activities.
(iv) A greater sense of ownership amongst the stakeholders for health services and activities.
INR 24 lakhs in first stage planning process @INR 50,000 per district
INR 9.60 lakhs in the second stage @ INR 20,000 per district.
In addition, at State level meetings/consultations, an estimated expenditure of INR 25000 was incurred.
Madhya Pradesh, since October 2005.
Encourages ownership: The process makes districts realise their own potential in managing health care delivery.
Simplicity: Special care was taken to make sure the guidelines were simple to understand.
Continuity: Guidelines need to be specific enough to ensure all districts produce similar plans.
Inclusiveness: Important to encourage all the stakeholders to attend planning workshops which ensure a more detailed and comprehensive plan.
State Government commitment to decentralisation.
Who needs to be consulted
All stakeholders: PRIs, field level workers, private sector providers, NGOs, Government officers at state and district level.
The process is sustainable throughout the State.
For example, in Guna, improved coordination is now perceptible between Integrated Child Development System (ICDS) and health. A Nutrition Rehabilitation Centre is now functional at the district hospital for severely malnourished children up to the age of 5 years.
Chances of Replication
Judged to be good.
Further decentralisation is now planned in the State in the form of Village Health Plans via the National Rural Health Mission (NRHM) agenda. The process is planned to be taken up in year 2006-07.
Clare Kitchen, Research Consultant, ECTA, New Delhi. March 2006.