Reproductive & Child Health

Programme Phase II
3
rd
Joint Review Mission
January 15 February 8, 2007


AIDE MEMOIRE
March 2007













DONOR COORDINATION DIVISION
MINISTRY OF HEALTH & FAMILY WELFARE
GOVERNMENT OF INDIA










CONTENTS
S.NO. PAGE NO.
1. INTRODUCTION 1
2. EXECUTIVE SUMMARY 1
Progress against program objectives 1
Progress since JRM2 2
Key areas requiring attention 4
Agreed key actions 5
Key Observations of the Secretary Health and Family Welfare
during the Wrap up Session of the Third JRM (8
th
February, 2007)
5
Observations of the JRM Chairperson 6
3. PROGRESS TOWARDS PROGRAM OBJECTIVES 7
4. MATERNAL HEALTH 8
5. CHILD HEALTH 12
6. FAMILY PLANNING 15
7. ADOLESCENT AND REPRODUCTIVE SEXUAL HEALTH 17
8. PROGRAM MANAGEMENT 18
9. ACCESS AND EQUITY 20
10. TRAINING 21
11. INNOVATIONS IN SERVICE DELIVERY 22
12. DEMAND CREATION 25
13. MONITORING AND EVALUATION 26
14. PROCUREMENT 27
15. FINANCIAL MANAGEMENT 29
16. NE DIVISION / NE-RRC 32

ANNEXES

ANNEX NO.
A JRM 3 PROCESS MANUAL
33
B STATE WISE DATA ON MMR, IMR AND TFR
78
C PERFORMANCE OF STATES AGAINST RCH II GOALS
79
D IMPLEMENTATION STATUS OF PRIORITY ACTIONS AGREED
TO IN SECOND JRM
80
E FINANCIAL MANAGEMENT
87
F STATE REPORTS
91


The cover is a reproduction of a Jamini Roy painting titled Mother and Child, courtesy of the National Gallery of Modern Art, New Delhi


LIST OF ABBREVIATIONS

ANC : Antenatal care
ANM : Auxiliary Nurse and Midwife
ANMTC : ANM Training Centre
ARI : Acute Respiratory Infection
ARSH : Adolescent Reproductive and Sexual Health
ASHA : Accredited Social Health Activist
AWW : Anganwadi Worker
AYUSH : Ayurveda, Yoga, Unani, Siddha and Homeopathy
BCC : Behaviour Change Communication
BPL : Below Poverty Line
CBO : Community Based Organisation
CHC : Community Health Centre
CTI : Collaborating Training Institute
CTP : Comprehensive Training Plan
DAP : District Action Plan
DC : District Collector
DC Division : Donor Coordination Division
DHAP : District Health Action Plan
DHFW : Department of Health and Family Welfare
DH : District Hospital
DHO : District Health Officer
DHRC : District Health Resource Centre
DHS : District Health Society
DLHS : District Level Household Survey
DP : Development Partner
DPMU : District Programme Management Unit
DWCD : Department of Women and Child Development
EAG : Empowered Action Group
EC : Emergency Contraception
EmOC : Emergency Obstetric Care
EPW : Empowered Procurement Wing
FMG : Finance Management Group (MOHFW)
FMR : Finance Management Report
FNGO : Field NGO
FOGSI : Federation of Obstetric and Gynaecological Societies of India
FP : Family Planning
FRU : First Referral Unit
GMP : Good Management Practices
GoI : Government of India
HBNCC : Home Based Newborn and Child Care
HP : Himachal Pradesh
HR : Human Resource



LIST OF ABBREVIATIONS (CONTD..)

HRD : Human Resource Development
J & K : Jammu & Kashmir
ICDS : Integrated Child Development Scheme
IEC : Information, Education, Communication
IMEP : Infection Management and Environment Plan
IMNCI : Integrated Management of Neonatal and Childhood Illness
IMR : Infant Mortality Rate
IPHS : Indian Public Health Standards
ISM : Indian System of Medicine
IUD : Intra Uterine Device
JRM : Joint Review Mission
JSY : Janani Suraksha / Suvidha Yojna
LHV : Lady Health Visitor
M&E : Monitoring and Evaluation
MDG : Millennium Development Goal
MIES : Monitoring Information and Evaluation System
MMR : Maternal Mortality Ratio
MNGO : Mother NGO
MO : Medical Officer
MoHFW : Ministry of Health and Family Welfare
MOU : Memorandum of Understanding
MPW : Multipurpose Worker
MTP : Medical Termination of Pregnancy
NERRC : North East Regional Resource Centre
NFHS : National Family Health Survey
NGO : Non Government Organisation
NHSRC : National Health Systems Resource Centre
NIHFW : National Institute of Health and Family Welfare
NRHM : National Rural Health Mission
PHC : Primary Health Centre
PIP : Programme Implementation Plan
PMSG : Programme Management Support Group
PMU : Programme Management Unit
PMSU : Programme Management Support Unit
PNDT : Pre Natal Diagnostic Techniques
PPP : Public Private Partnership
PRI : Panchayati Raj Institutions
RCH : Reproductive and Child Health
RET : Regional Evaluation Team
RKS : Rogi Kalyan Samiti
RRC : Regional Resource Centre
RTI : Reproductive Tract Infection
SBA : Skilled Birth Attendant


LIST OF ABBREVIATIONS (CONTD..)

SC&ST : Schedule Castes and Scheduled Tribes
SHC : Sub Health Centre
SHS : State Health Society
SHM : State Health Mission
SIHFW : State Institute of Health and family Welfare
SN : Staff Nurse
SPMU : State Programme Management Unit
SHSRC : State Health Systems Resource Centre
STI : Sexually Transmitted Infection
TFR : Total Fertility Rate
TNMSC : Tamil Nadu Medical Services Corporation
TOR : Terms of Reference
TOT : Training of Trainers
UC : Utilisation Certificate
UP : Uttar Pradesh
UT : Union Territory
REPRODUCTIVE AND CHILD HEALTH PROGRAM, PHASE II
THIRD JOINT REVIEW MISSION: JANUARY 15-FEBRUARY 8, 2007

AIDE MEMOIRE

1. INTRODUCTION

The Third Joint Review Mission (JRM3) of the Reproductive and Child Health Program,
Phase II (RCH II) primarily assessed progress made by states in terms of outcome indicators
for maternal health, child health and family planning; evaluated corresponding strategies and
identified key implementation bottlenecks. Agreements on the way forward were reached
within the acknowledged core principles of RCH II that included strong pro-poor focus to
reduce inequities, ensure gender mainstreaming, enhance state ownership through bottom-
up planning, promote evidence based policies and interventions to ensure quality of care,
and strengthen results measurement. RCH II is an important and integral component of
National Rural Health Mission (NRHM) as several initiatives envisaged under the NRHM
such as Accredited Social and Health Activist (ASHA) for community mobilization and untied
funds to health facilities directly contribute to outcomes expected of the RCH II program.

The JRM3 held during January 15 to February 8, 2007 was led by Ministry of Health &
Family Welfare (MOHFW) and joined by state representatives and all development partners
supporting RCH II program. In depth field visits were made to 3 high focus states i.e. Uttar
Pradesh, Madhya Pradesh and Tripura followed by a comprehensive review of program
implementation at central and state levels in New Delhi chaired by Mrs. Jalaja, Additional
Secretary MOHFW and National Mission Director for NRHM (refer Annex A for the Process
Manual for JRM3). This aide-memoire summarizes the findings of the JRM and agreed
actions for the way forward.


2. EXECUTIVE SUMMARY

Progress against program objectives

IMR for India has improved from 68 (SRS 2000) to 58 (SRS 2005), MMR from 327 (SRS
1999-01) to 301 (SRS 2001-03) and TFR from 3.2 (SRS 2000) to 2.9 (SRS 2004). However,
the figures are nowhere close to the 2007 goals of < 45, < 200 and < 2.3 for IMR, MMR and
TFR respectively; the corresponding RCH II goals for 2010 are <30, <100 and <2.1
respectively.

There is considerable variation across states (refer Annex B for statewise data on MMR,
IMR and TFR). The IMR goals for 2010 and 2007 have been achieved by 7 and 13 states
respectively. These states account for only 4.1 and 34.3% of the all India population (Census
2001). With an MMR of 110, Kerala is closest to achieving the 2007 goal of < 100, while 8
states (43.1% of country population) have achieved the 2007 goal of <200. The TFR goals
for 2010 and 2007 have been achieved by 6 (17.6% of population) and 10 states (42.3% of
population) respectively.

A preliminary analysis of states in terms of current status of MMR, IMR, TFR and past trends
in terms of selected maternal health, child health and family planning indicators suggests
that states could be grouped into 4 categories with Category 1 being the best and category 4
being the worst. Category 1 consists of 3 states (Kerala, Goa and Sikkim), while categories
2, 3 and 4 consist of 6, 12 and 7 states respectively. Category 4 consists of Bihar,
Jharkhand, Rajasthan, Uttar Pradesh, Arunachal Pradesh, Assam and Nagaland. Categories
3 and 4 account for about 39% and 34% respectively of the All India 2001 population.

- 2 -

Progress since JRM2

Since the 2
nd
JRM in October 2006, MoHFW has made significant progress on the following:

Approximately 4 lakhs ASHAs have been trained and recruited across the country.
There has been a marked improvement in the public health delivery system through
the network of Sub centres, PHCs and CHCs.
The PMUs have enhanced the programme implementation and flow of data and
information from Districts /States and Centre especially in the North East. A total of
1682 Programme Management Officials have been appointed across the country
with 482 in the erstwhile EAG States.
JSY has been highly successful with the number of beneficiaries having gone up
from 6 lakhs to 21 lakhs. The scheme is being evaluated with the help of DPs in eight
states and results are likely to be available before the next JRM. The evaluation will
also assess the percentage of poor as well as SC/ST who benefited from the
scheme.
The Gadchiroli-like model for Home Based Newborn and Child Care (HBNCC) has
been adapted and guidelines finalised. In non-IMNCI districts, initial steps have been
taken in 10 districts in 5 states (UP, Bihar, Orissa, Rajasthan, and MP) to implement
HBNCC under the Norwegian India Partnership Initiative.
Over one million Monthly Village Health and Nutrition days have been held at
Anganwadi Centres across the country. This initiative brings together a range of
services from RCH, ICDS and other sectors to the community.
There is more visibility for EC now and states are making demands for supplies. NSV
kits have been procured centrally. Specifications for laparoscopes have been shared
with states and states are going ahead with the procurement. A social franchising
scheme for IUD and an alternative strategy for IUD insertion training have been
worked out as a pilot in a few states.
The system put into place by the Finance Management Group (FMG) has led to
considerable improvement in release of funds and 20 states are sending their
Financial Monitoring Reports (FMRs) on time. Further, a decision has been taken to
support an accountant at all PHCs.
The Program Management Support Group (PMSG) at the centre is fully functional.
Training programmes for state teams on DHAP are underway in collaboration with
Lal Bahadur Shastri National Academy of Administration, Mussoorie. About 130
officials across 21 states have been trained so far. The training covers financial
management, planning process, prioritisation, etc.
GoI has decided to have integrated training programmes for the NRHM components
and a common training calendar under the Training Division.
The MNGO TOT manual has been developed. 300 MNGOs have been trained in
RCH and the FNGO handbook has been finalised.
A framework for strengthening intra-communication has been developed and recently
shared with the states. The NRHM branding has been further strengthened and
independent tracking data indicates that NRHM was the most visible brand in
government communication on TV. Integrated BCC for all NRHM components is
being planned by the IEC Division.
NFHS3 results for 29 states and India are now available. MOHFW has decided that
the Annual Health Survey, which is being planned to be conducted by the Registrar
General of India for preparing the district health profiles, will also include the datasets
for other related departments.
Draft user guidelines for reporting in the new MIES format have been prepared and
circulated. Eight states have started reporting data on the new format.



- 3 -
Protocols for Quality Assessment have been prepared and are being piloted in six
states.
The study by IIM-Ahmedabad for evolving a methodology to capture process
indicators on management has been completed. A pilot has been undertaken in 3
EAG & 2 Non-EAG states; subsequently, tools have been refined and disseminated
to all states.
Crown Agents, the consultant working on capacity building for EPW has completed
the recruitment of six full time staff; prepared a draft IT strategy and a draft
procurement manual and formulated an arrangement to provide oversight to all the
procurement being handled by EPW. MoHFW has signed a MoU with United Nations
Office for Project Services (UNOPS) for acting as the procurement agent but the
Agreement in the World Banks standard format is yet to be executed.
Various state innovations are being documented by MOHFW for publication and
wider dissemination.
National guidelines on prevention and management of RTIs, including STIs have
been developed jointly with NACO and have been disseminated to the states. Draft
operational manual on RTIs/STIs for programme managers & service providers in
public health systems has also been developed and is in the process of finalization.
In addition, guidelines for training of ANMs/SNs in Skilled Birth Attendance (SBA)
and for training of Medical Officers (MOs) in management of complications of
pregnancy at 24x7 PHCs have been prepared. Policies on revised vitamin A age
schedule and Zinc as an adjunct therapy with ORS for diarrhoea have been finalised.
A technical committee has recommended cotrimoxazole use by trained AWW/ASHA
but final approval from DCG (I) is still awaited. Similarly, a technical committee has
been formed to finalise new guidelines for management of sick children including
newborn, diarrhoea and severe malnutrition for referral care at FRUs. This is
expected to be completed shortly. Additionally, guidelines on management of
diarrhoea are being revised.
The scope of work of FMG is now enhanced to cover NRHM.

Since the 2
nd
JRM, states have made progress on the following:

More than 100 districts have indicated plans for IMNCI implementation. Increasingly
major states are accelerating actions to rollout IMNCI in a greater number of districts
(Rajasthan, Orissa, Uttar Pradesh, Bihar, Gujarat, and Madhya Pradesh).
Consistent supply of auto-disable syringes and vaccines has been increasingly
ensured throughout the states. The recent coverage surveys have shown
improvements in immunisation in several states (Bihar, UP, Assam, Nagaland,
Meghalaya etc); however, several other states have shown a decline (Gujarat,
Maharashtra, etc.).
All states have initiated procurement of Kit A, Kit B and laparoscopes. The NE states
(apart from Arunachal) have entered into an arrangement with TNMSC for
procurement.
1682 candidates have been recruited to staff the DPMUs/SPMUs; Uttar Pradesh and
J&K are yet to take any steps in this context.
NE states have made significant progress on recruitment and training of programme
management support units at state and district levels.
Out of 33,000 ASHAs required for the NE states, 27275 have been recruited.
Orissa, Rajasthan and Gujarat are all examples of states that are mapping the
distribution of health facilities in order to identify gaps in coverage.
States such as TN, Rajasthan, and Haryana are providing incentives to get ANMs
and other workers to serve in rural areas. MP has set an excellent example by
funding SC/ST and other students to study nursing; after completion of their training

- 4 -

these women will serve in MP for five years. Gujarat has included specifications for
ramps in all new facilities to facilitate access by disabled people.
MP has initiated concurrent internal audit of districts and sub districts.

Out of the total approved RCH II flexible pool allocation of Rs 1833 Crores, maternal health,
child health (excluding routine immunisation and polio) and family planning accounted for
28%, 3 % and 22% respectively. JSY accounted for almost 29% of the Maternal Health
allocation. Total expenditure until September 2006 was about 14% of the total allocation;
there are wide variations across states: Chhattisgarh, Arunachal and Mizoram have spent
more than 50% of their allocation, while 10 states have spent less than 10%.

Key areas requiring attention

Key areas that require attention are:

Throughout the JRM, the need for more focused attention on Child Health (CH) and
especially newborn care was quite evident. IMNCI is being taken up in about 100
districts. The entire focus seems too centred on Immunisation and IMNCI and there
is likelihood of CH in remaining districts and the care of newborn being further
neglected. An alarming observation was the decline in ORS use rates in most states
as reported by NFHS 3.
Different divisions have prepared guidelines on various technical interventions and
these require implementation. The dissemination of these guidelines needs to be
done urgently through meetings and workshops to enable the states to clearly
understand the implementation details. Implementation status may be reviewed by
future JRMs.
Implementation of training programmes is slow. Less than 10% of the 06-07 training
load for SBA and emergency obstetric care have been completed.
A large number of innovative practices are under implementation in both high focus
and other states. Though some of the innovative approaches are being evaluated or
have plans in place for undertaking an assessment, several of the innovations
require proper external evaluations before scale-up to ensure that they are
addressing critical gaps in the programs and improving the utilization of services
especially by the vulnerable population.
Uttar Pradesh constitutes about one sixth of Indias population and contributes to an
even larger share of the countrys disease burden. The basic structures and systems
for running large-scale public health programmes like the NRHM including RCH need
to be put into place urgently and firmly.
Increasing access to family planning services for addressing unmet need for both
limiting and spacing methods is critical to achieve goal of TFR of 2.1 by 2010.
Though there has been some decline in the unmet demand, and contraceptive
prevalence rates have gone up since NFHS2, there are wide variations across the
states. Unmet demand still remains unacceptably high in the high focus states.
Greater progress needs to be made in the use of emergency contraception, including
through inclusion in the ASHA kit.
Progress has been slow in the procurement of drug kits.
Completion of the procurement audit is a requirement for retroactive funding from
the Bank; this requires immediate attention. While there is a need to strengthen
EPW, delay in filling vacancies of senior positions, especially of Joint secretary, as
well as delay in finalizing the contract with UNOPS is a cause of concern. In addition,
a focal point needs to be identified for all actions on the Governance and
Accountability Action Plan.


- 5 -
As per the agreements, a mid-term review of RCH II is to be carried out 24 months
from inception of the programme i.e. about the time of JRM-4. The third round of the
District Household Surveys (RCH II survey) was planned to be completed in time to
inform this mid-term review on program achievements. This survey is yet to be
started.
Safe abortion services are not receiving adequate attention in most states. States
need to ensure greater monitoring and enforcement of the MTP Act.
Guidelines for Infection Management and Waste Disposal are yet to be finally
approved and distributed to states. Field visits confirm that this is an area that
requires a lot of attention.

Agreed key actions

(a). By March 2007, NHSRC will be made fully functional with all development partners
nominating their representatives on the advisory board, a full time director in place
and an approved business plan.
(b). By April 2007, the Training Division will firm up prepare a national strategy and plan
for upscaling training across all states, with the engagement of the DPs. The plan will
identify alternative training service providers and specify roles of the Training
Division, NIHFW, NERRC and states in meeting the total training load as well as
mechanisms for monitoring progress and quality/ impact of training.
(c). By March 2007 reactivate the M&E working group and start process for contracting
agencies for concurrent evaluation.
(d). By May 2007, M&E Division will evolve a framework for triangulation of data on use
of essential RCH services, and within two months thereafter, initiate a pilot.
(e). By March 2007 initiate regional dissemination of technical including IMEP guidelines
of the program through regional workshops; complete the process by next JRM
(f). By April, 2007 set up programme management support arrangements in UP
(g). By February 28, 2007, submit the procurement audit reports for the year 2005-06 to
enable IDA to disburse their share against the eligible expenditure incurred.
(h). By June 2007, IEC Division will prepare an integrated BCC plan for addressing all
NRHM components (including RCH) in consultation with all the programme divisions.
(i). By March 2007, all key positions in EPW will be staffed.
(j). By April 2007, all states/UTs will provide the following detailed lists to Infrastructure
Division for uploading on MOHFW website:
1. Facilities identified for upgradation to FRUs (as per GoI guidelines)
2. PHCs for providing 24 hr services
3. CHCs for upgradation to IPHS
4. Sub-centres functional with at least one ANMs and operational joint account with
Gram Pradhans
(k). By the mid-term review, results of DLHS 3 survey will be made available.


KEY OBSERVATIONS OF THE SECRETARY HEALTH AND FAMILY WELFARE DURING
THE WRAP-UP SESSION OF THE THIRD JOINT REVIEW MISSION (8
th
February, 2007)

(a) Enforcement of the PC & PNDT Act needs to be strengthened by: changing the
competent authority for enforcement from the CMO to the District Magistrate and
considering greater penal action for violations of the act.
(b) There needs to be greater convergence between NRHM and National AIDS Control
Programme as HIV positive cases in Andhra Pradesh and Karnataka are a cause of
concern.



- 6 -

(c) Multiskilling of doctors to be undertaken at the earliest possible in conjunction with
UNFPA and FOGSI and the reply to the PIL filed against such training may be
strengthened by all the concerned parties showing active concern.
(d) Enhanced focus on establishing a primary health care structure in the urban slums
(an initiative under the RCH-II).
(e) There is a need to expedite procurement reforms and institutionalize them at the
earliest.
(f) District Hospitals may be considered for establishing Medical colleges under PPP by
the States in their NRHM State PIP.

Observations of the JRM Chairperson

States may identify the nodal officers for Procurement, CH, MH, Financial
Management, and Family Planning for establishing effective linkages between the
State and the Centre.
RCH-Finance may see to adjustment of unspent balances of the RCH-I with the
States against releases for the next financial year (2007- 2008) as per the guidelines
issued by Ministry of Finance.
States may take up concurrent audit for effective financial management and
reporting.
Financial Management Groups may be set up at the State level in natural
progression of the FMG at the Centre.
Medical colleges should support states with inadequate training facilities especially in
priority areas like multi-skilling of doctors and SBA training. Maternal Health and the
Training Division may coordinate.
The proposals related to infrastructure by the States under RCH-II may be integrated
with the NRHM.
States need to focus on routine immunization where coverage is less.
Pulse Polio and Immunization may be considered as interventions for Child Health
under RCH-II and reflected accordingly.
The next years NRHM PIP to have RCH component separately as RCH chapter
(under the PIP).
The Ministry may share the organisation chart of EPW with the Programme Divisions,
DPs and the States.
States may plan for convergence of ANM, ASHA and the Anganwadi worker at the
village /community level for village health and nutrition day which should be
organised regularly.
Proposals from DPs to provide assistance in establishing monitoring, logistic
arrangement, supply chain management are welcome.
Quality assurance committees established at districts may be used for accreditation
of facilities as FRU.
The Ministry will collect monthly reports from NGOs and will upload the same on the
Ministrys website.
Family planning related IEC activities by states should focus on:
1. Age at marriage / PNDT/ Institutional Delivery and unmet demand.
2. School Health Programmes to be taken up by all the states.
3. IEC at School level may be taken through text books and school plays.
States may motivate ANMs through ensuring appropriate avenues for career
progression.
Ministry needs to examine the suitability of the role of cooperative societies under the
MNGO scheme.

- 7 -
JSY has been instrumental in promoting institutional deliveries to a great extent.
However the usage of JSY funds requires a sample check to ensure that the money
is being used by the beneficiary
ASHAs in tribal areas need to be appointed in all the states.
States need to take up Social Audit of Maternal Deaths to identify underlying factors
States may use beauty parlours as a channel for IEC activities / social marketing of
family planning devices.
States may start publishing the innovations implemented by them in a book form.
Emergency contraceptive pills need to be promoted and ASHA kit may also include
the same.
MOHFW requests DPs to support training programme in NE states.
States now need to focus on block and primary support units in the next year.
States need to have convergence of HIV AIDS, Malaria etc with RCH II.
States may ensure provision of a link worker in all the slum areas under RCH-II.
States may initiate action for establishing nursing cadre in their state.
States may plan one Nursing Institute in every district of their state with private
participation
States may start publishing State NRHM news letter in their local language

3. PROGRESS TOWARDS PROGRAM OBJECTIVES

Progress against MMR, IMR, TFR

The most recent data on IMR (SRS 2005), MMR (SRS 2001-03) and TFR (SRS 2004) does
not reflect the full impact of the momentum gained under RCH II. Available data for the
country as a whole indicates that IMR, MMR and TFR have shown a positive trend, although
the performance is nowhere close to the Tenth Plan (2007) goal:

MMR IMR TFR
SRS
1999-01
SRS
2001-03
SRS 2000

SRS 2005

SRS 2000 SRS 2004
India 327 301 68 58

3.2 2.9
10
th
Plan Goal
(2007)
< 200 < 45 < 2.3
RCH II Goal
(2010)
< 100 < 30 < 2.1

Not unexpectedly, there is a wide variation in performance across states (see Annex C):

Out of 28 states, Kerala, Goa and Sikkim have already achieved the RCH II 2010
goal for both IMR and TFR.
With a MMR of 110, only Kerala is closest to achieving the 2010 goal of <100.
However, an additional 7 states i.e. Andhra Pradesh, Gujarat, Goa, Maharashtra,
Punjab, Tamil Nadu and West Bengal have achieved the Tenth Plan MMR goal of
<200. MMR data is not available for 10 states.

- 8 -
Seven states i.e. Manipur, Mizoram, Nagaland, Sikkim, Tripura, Goa and Kerala
have already met the IMR RCH II goal of <30 by 2010. An additional six states i.e.
Uttarakhand, Arunachal, Maharashtra, Punjab, Tamil Nadu and West Bengal have
met the 2007 goal of <45.
Six states i.e. Himachal Pradesh, Sikkim, Andhra Pradesh, Goa, Kerala, and Tamil
Nadu have achieved the National TFR goal of < 2.1. In addition, Karnataka,
Maharashtra, Punjab, and West Bengal have met the 2007 goal of <2.3.
Ten states i.e. seven EAG states (Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh,
Orissa, Rajasthan, and Uttar Pradesh), J&K, Assam and Haryana have not achieved
any of the 3 goals for 2007. Uttarakhands IMR of 42 is somewhat better than the
goal of 45 by 2007.

A preliminary analysis of states was carried out in terms of current status of MMR, IMR, TFR
and past trends in terms of 11 outcome indicators i.e. neonates who were breastfed during
first hour of life; neonates who were breastfed exclusively till 6 months of age; infants
receiving complementary feeds apart from breast feeding at 9 months; 12-23 month children
fully immunized; children 6-35 months who are anaemic; pregnant women getting full ANC;
pregnant women who are anaemic; deliveries by skilled birth attendants; contraceptive
prevalence rate for any modern method; unmet need for spacing methods and terminal
methods among eligible couples. The analysis suggests that in terms of RCH outcomes,
states can be grouped into 4 categories with category 1 being the best and category 4 being
the worst:

Category 1 Category 2 Category 3 Category 4

Goa Uttaranchal Chhattisgarh Bihar
Kerala Himachal
Pradesh
Madhya
Pradesh
Jharkhand
Sikkim Karnataka Orissa Rajasthan
Maharashtra Andhra Pradesh Uttar Pradesh
Tamil Nadu Gujarat Arunachal Pradesh
Manipur Haryana Assam
J & K Nagaland
Punjab
West Bengal
Meghalaya
Mizoram
Tripura
Total Population
in lakhs
337 2289 4080 3624
Category pop. as
% of India pop
3 22 39 34


4. MATERNAL HEALTH

Not surprisingly, NFHS3 indicates wide variations across states for maternal health
indicators. Amongst high focus states, several NE states, Himachal Pradesh and Jammu &
Kashmir fare somewhat better than most EAG states:

Pregnant women receiving at least three antenatal checks ranges from 16.9% in
Bihar to 96.5% in Tamil Nadu. Within EAG states, Orissa at 60.9% and Chhattisgarh
at 54.7% have performed better.

- 9 -
Skilled attendance at birth ranges from 25.9% in Jharkhand to 99.7% in Kerala.
Orissa and Chhattisgarh are again among the better performers amongst EAG
states.
Deliveries in government and private institutions again show a wide variation with
Nagaland at 12.2% and Kerala at 99.5%. Among the EAG states, Orissa is at 38.7%
and Uttarakhand at 36.0%, while Chhattisgarh and Jharkhand are at 15.7% and
19.2% respectively.
Pregnant women with anaemia are at very high levels in most states, the range being
29.9% in Delhi to 72.0% in Assam. Among the EAG states, Uttarakhand is the lowest
at 45.2% while all the others are above 50%. Even several non-high focus states fare
very poorly on maternal anaemia, with Haryana, West Bengal, Gujarat, and
Karnataka being amongst the top ten states with the worst indicators.

Between NFHS 2 (1998-99) and NFHS 3 (2005-06), there has, in general, been an
improvement in maternal health across all states:

Proportion of women getting at least three antenatal checks has improved across
states. Several high focus states like Sikkim, Chhattisgarh, Uttarakhand, Rajasthan,
Orissa, Meghalaya and Manipur have shown significant improvement
Proportion of deliveries attended by health personnel has again shown improvement.
Within high focus states, this is most marked in the case of Sikkim, J&K, Orissa,
Chhattisgarh, Jharkhand, Assam and Meghalaya.
Institutional deliveries have increased across all states particularly with Sikkim, J&K,
Himachal Pradesh, Uttarakhand and Manipur.
However, maternal anaemia has worsened across most states especially Bihar,
Rajasthan, Andhra Pradesh, Gujarat, Haryana, Kerala, Karnataka and Assam.
Interestingly, states like Chhattisgarh, Uttarakhand, J&K, Tamil Nadu, Delhi and
Meghalaya have reversed the trend.

Progress since 2nd JRM

As noted in the 2nd JRM, the maternal health division has produced and disseminated
comprehensive technical guidelines to the states. Since the 2nd JRM, national guidelines on
prevention and management of Reproductive Tract Infections (RTIs), including Sexually
Transmitted Infections (STIs) have been developed jointly with National AIDS Control
Organization (NACO) and have been disseminated to the states. Draft operational manual
on RTIs/STIs for programme managers & service providers in public health systems has
also been developed. It will be piloted before finalization. Guidelines for training of Auxiliary
Nurse Midwives (ANMs)/Staff Nurses (SNs) in Skilled Birth Attendance (SBA) have been
finalized. However, field visits indicated continued variations in the availability, understanding
and therefore implementation of all program guidelines. The six regional workshops and
subsequent state visits by a team of experts to ensure accurate understanding of guidelines
and strategies by managers and service providers have not been held.

Though guidelines for training of Medical Officers (MOs) in management of complications of
pregnancy at 24x7 PHCs have been prepared, guidelines for conducting training have not
been finalized. Consequently, training of MOs has not gained momentum in most, including
well performing states. For multi skilling of MOs on comprehensive obstetric care, including
caesarean sections, steps are being taken by MOHFW in collaboration with FOGSI to
increase the capacity for training of trainers by identifying more nodal centres (medical
colleges) at the regional level. However, this process needs to be accelerated on a priority
basis, as this training along with anaesthesia training is a critical input for operationalisation
of the First Referral Units (FRUs). In most major states, medical colleges have been
identified and orientation of faculty in 55 medical colleges has taken place along with release

- 10 -

of funds for equipping departments of anaesthesia. It is understood that a Public Interest
Litigation (PIL) has now been filed in the Delhi High Court against this training programme.
MOHFW intends to respond by engaging the best legal expertise, besides taking other
appropriate steps such as creation of awareness on maternal mortality issues through the
media.

SBA training needs to receive focused attention and states may consider the example of
Karnataka where each medical college has been allocated one district for training of
ANMs/SNs as SBAs.

Though 1858 FRUs across the country were reported to have been operationalised,
observations during field visits noted that some of the FRUs were not fully functional
according to GOI guidelines. Some states such as Tamil Nadu and Madhya Pradesh have
initiated the process of certifying the functional status of FRU/CEmONC facilities for which
they have evolved their own criteria. Similarly, most high focus states are making 24X7
facilities operational, but adequate manpower needs to be in position to make them fully
operational per GoI guidelines. GoI has already disseminated FRU operational guidelines to
states. States should take initiative in certifying the FRUs as per these guidelines.

The Janani Suraksha Yojana (JSY) scheme has shown initial success in various states with
very substantial increases in the number of institutional deliveries. The guidelines have been
revised and the quantum of assistance under the scheme has also been increased. The
revised guidelines have been issued to the States and a set of frequently asked questions
have also been developed and are available on the website. An area of concern is the extent
to which the poor are using the scheme; JSY is being evaluated with help of DPs in eight
states and results are likely to be available before the next JRM. It is important to track the
percentage of poor as well as SC/ST who benefit from the scheme.

Field visits indicated that in many states, Dilatation and Curettage (D&C) is still being used
for abortion services instead of the preferred method of Manual Vacuum Aspiration (MVA).
Provision of safe abortion services needs to get higher priority as unsafe abortions account
for about 10% of all maternal deaths. There is little awareness amongst health workers or
the public of the important and safe role that Emergency Contraception can play in
preventing unwanted pregnancies.

Developing referral linkage is an important RCH strategy and is critical to maternal survival.
It is important that all states develop this by learning from some of the states that have
developed these models successfully.

Areas of Concern

(a) Uneven availability and understanding of technical guidelines are resulting in
variations in implementation. The proposed dissemination workshops have not yet
been held.
(b) States have not linked the training with operationalisation of facilities.
(c) While 1858 FRUs have been reported as fully operational, field visits indicate the lack
of the full complement of inputs. As noted above, states should follow GoI FRU
guidelines in this regard, and take initiative in certification of such FRUs accordingly.
(d) In states with limited availability of specialists, it would be more prudent to first
establish levels of care according to FRU guidelines, i.e. operationalise FRUs first
while the long-term focus should continue to be on IPHS standards.
(e) Training of ANMs as SBAs is not receiving due attention at the state level. Provision
of drugs kits and drugs like Misoprostol and injection magnesium sulphate to the
ANMs need urgent attention.

- 11 -

(f) Training of MOs in basic emergency obstetric care has not been initiated in most of
the states. Training guidelines need to be developed urgently.
(g) Slow pace of the comprehensive emergency obstetric and neonatal care training.
(h) Worsening anaemia in women highlights the need to better address the nutritional
status of women both before and during pregnancy.
(i) Guidelines on Infection Management and Environment Plan are yet to be finally
approved and distributed to states. Field visits confirm that this is an area that
requires a lot of attention.
(j) Safe abortion services are not receiving adequate attention in most states.
Additionally, states need to ensure greater monitoring and enforcement of the MTP
act through competent authority at the district level to reduce unsafe abortions.
(k) Public facilities are facing serious capacity constraints in meeting increased demand
for institutional deliveries as a result of JSY. Further, quality of institutional deliveries
may not be of acceptable standards.

Agreed Actions

Actions pending from 2
nd
JRM

(a) By March 2007, NHSRC will provide 3-4 technical consultants to Maternal Health
Division. This group will provide on-site support to the focus states in developing a
training strategy and plans and ensure availability of training material, trainers and
examiners, especially for anaesthesia training. They would also provide support to
states in preparing plans for monitoring training quality and post training follow ups
for highly skilled clinical trainings.
(b) During February-April, 2007, MOHFW, with support from DPs and with involvement
of experts will conduct at least 6 workshops for dissemination of technical guidelines
and facilitating improved understanding of maternal health strategies. Action plans for
holding follow up workshops by high focus states in their districts will be one of the
outcomes from the workshops.
(c) By March 2007, advise all focus states to prepare plans for refresher training in SBA
for freshly passed ANMs in government sector and inclusion of contents of SBA in
pre-service training of ANMs and SNs in consultation with Advisor (Nursing) and
Training Division.

Other Actions

(d) By March 2007, states should be informed to devise an appropriate institutional
mechanism for accrediting the operational FRUs as per the GoI guidelines (e.g. the
quality assurance committees at state and district levels could be involved).
(e) By March 2007, advise states to ensure distribution of insecticide treated bed nets in
malaria endemic areas to pregnant women at the time of ANC registration. These
nets should be provided under National Vector Borne Diseases Control Project.
(f) By March, 2007 finalise the IMEP guidelines and disseminate as part of the
workshops mentioned above.
(l). By April 2007, all states/UTs will provide the following detailed lists to Infrastructure
Division for uploading on MOHFW website:
1. Facilities identified for upgradation to FRUs (as per GoI guidelines)
2. PHCs for providing 24 hr services
3. CHCs for upgradation to IPHS
4. Sub-centres functional with at least one ANMs and operational joint account with
Gram Pradhans

- 12 -

5. CHILD HEALTH

NFHS 3 (2005-06) again indicates wide variations for child health indicators:

a. Early initiation of breastfeeding is at 4.0% in Bihar, 7.2% in UP, up to 65.4% in
Mizoram. The other EAG states have poor figures, except Orissa at 54.3%. NE
states, HP and J&K fare somewhat better.
b. Exclusive breastfeeding in children less than 6 months is at 82% in Chhattisgarh,
while Jharkhand, Orissa and UP have figures above 50%. Other high focus states
have mixed results. Haryana and Goa at 16.9% and 17.7% are at the bottom.
c. Complementary feeding in children 6-9 months age is above 50% in most states with
Kerala at 93.6% and Rajasthan at 38.7%. Only Haryana, UP and Maharashtra are
the other states with figures below 50%. NE states have better results among high
focus states.
d. Full immunisation in children age 12-23 months ranges from 21.0% in Nagaland to
80.8% in Tamil Nadu. Among the high focus states, HP (74.2%), Sikkim (69.6%),
J&K (66.7%) and Uttarakhand (60.0%) are the better performers.
e. ORS use in children < 3 years age is very low 12.0% in UP to 67.7% in Meghalaya,
with only 4 other states (Tripura, HP, Goa and Mizoram) showing use above 50.0%.
f. Anaemia in children age 6-35 months shows some alarming figures. Twelve states
have more than three-fourths of its children under 3 years age with anaemia Bihar
at 87.6%, Uttar Pradesh at 85.1%, Karnataka at 82.7% and Madhya Pradesh at
82.6%. Notably, only two states Goa and Nagaland, have levels below 50%.

Comparative analysis between NFHS 2 (1998-99) and NFHS 3 (2005-06) reveals some
areas of concern on child health indicators across states:

a. Early initiation of breastfeeding has decreased in Delhi, West Bengal and Bihar.
b. Full immunisation in children 12-23 months shows an interesting trend. States with
poor figures a few years ago seem to have undertaken intensive efforts resulting in
impressive gains. On the other hand, states with good coverage seem to have
become complacent, resulting in reduced complete immunisation across the board
(except Haryana and J&K showing some improvement). High focus states like
Sikkim, Jharkhand, Chhattisgarh, Uttarakhand, Bihar and Madhya Pradesh have
notched up the maximum increases, while Maharashtra, Mizoram and Andhra
Pradesh have seen the maximum decreases.
c. ORS use in early childhood has shown a sharp increase in Meghalaya, and a lesser
improvement in some other focus states like Chhattisgarh, Bihar, HP, Mizoram and
Orissa. However, it is seen to be dropping across most states, most marked in
Assam, Manipur, Karnataka, Kerala and Nagaland.
d. Early Childhood anaemia has worsened across many states particularly in Assam,
Karnataka, Arunachal Pradesh, Uttar Pradesh and Madhya Pradesh. However, a few
states have actually reversed this trend. Sikkim has shown the maximum
improvement, with other focus states like Chhattisgarh, Jharkhand, Rajasthan,
Uttarakhand, HP, J&K, and Mizoram show some improvement.

Progress since 2nd JRM

At national level, recent policy decisions on revised vitamin A age schedule and Zinc as an
adjunct therapy with ORS for diarrhoea are now in place. A technical committee has
recommended cotrimoxazole use by trained AWW/ASHA but final approval from DCG (I) is
still awaited. Similarly, a technical committee has been formed to finalise new guidelines for
management of sick children including newborn, diarrhoea and severe malnutrition for
referral care at FRUs. This is expected to be completed shortly. Additionally, guidelines on
management of diarrhoea are being revised.

- 13 -

Most state PIPs have child health heavily focussed on IMNCI, with very little attention to
other strategies. Allocations for child health in state PIPs in 2005-06 and 2006-07 have
been extremely low. Likewise, very little progress has been made on implementation,
mirrored by the abysmal utilisation of funds.

More than 100 districts have indicated plans for IMNCI implementation. To accelerate
implementation, more training sites at national and state levels have been included and the
NIHFW has been appointed as the nodal agency for co-ordinating IMNCI training at a
national level. Standard training modules need to be followed for training of the different
types of field workers (ANMs, AWWs, etc.). Increasingly major states are accelerating
actions to rollout IMNCI in a great number of districts (Rajasthan, Orissa, Uttar Pradesh,
Bihar, Gujarat, Madhya Pradesh). Pre-service IMNCI in the teaching curriculum of
undergraduate medical students currently involves nearly 50 medical colleges and work has
started with the Indian Nursing Council to finalize the materials for teaching nursing students
and ANMs.

Increasing the coverage of IMNCI is slow, creating a disparity in access to neonatal and
child health services in non-IMNCI districts. Elements of IMNCI could be identified and
disseminated to ANMs and ASHAs more widely as part of routine training before the full
IMNCI package is introduced. The Gadchiroli-like model for Home Based Newborn and Child
Care (HBNCC) has been adapted and guidelines finalised. In non-IMNCI districts, initial
steps have been taken in 10 districts in 5 states (UP, Bihar, Orissa, Rajasthan, and MP) to
implement HBNCC under the Norwegian India Partnership Initiative.

Dialogue with professional bodies and NGOs is underway to support the rollout of the child
health strategy, including NGO support for training in IMNCI and newborn care. An
assessment of facility based essential newborn care currently underway, with results
expected shortly.

Where JSY is significantly increasing demand for institutional delivery, adequate skills for
SBAs for essential care of the newborn and adequate supply of equipment should be
ensured.

While all of the above actions will take time to be implemented widely, the states need to
renew focus on basic newborn care, promotion of breastfeeding, and on ARI and diarrhoeal
diseases management.

Immunisation weeks have been used to decrease proportion of un-immunised children. The
most recent rounds have reported a significant increase in coverage from previous rounds.
Consistent supply of auto-disable syringes and vaccines has been increasingly ensured
throughout the states. The recent coverage surveys have shown improvements in
immunisation in several states, (Bihar, UP, Assam, Nagaland, Meghalaya etc), however
several other better performing states have shown a decline (Gujarat, Maharashtra, etc.).
Additionally, immunisation progress is not uniform within the states. There is a need to
identify districts with poor coverage and remedial steps taken. Focus is required on
integrating routine immunisation and pulse polio immunisation with the health system.

Last year saw a surge in polio cases, following a four-year outbreak pattern, attributable to
slippage in SIA rounds and sub-optimal immune response to OPV. The International Expert
Advisory Group (IEAG) concluded that at end-2006, population immunity was at highest
level ever due to improvements in OPV coverage, use of monovalent OPV (mOPV) and the
recent outbreak, and that 2007 represents the best opportunity ever to interrupt wild
poliovirus type 1, with intense work to close the immunity gap in young children. The IEAG
recommended a schedule of national immunisation days (NIDs) and sub-national

- 14 -

immunisation days (SNIDs) for pulse polio. However, a substantial funding gap for
upcoming polio rounds has also been highlighted.

As noted above, child health has IMNCI as a key intervention across EAG states. However,
the progress of states on IMNCI has been rather slow: In Bihar 48 MOs, 148 ANMs and 631
AWWs have been trained across 6 districts; Rajasthan has completed TOT and actual
trainings have just begun in 9 districts; Orissa has completed TOT in 4 districts while actual
training of staff has been completed in 2 districts; MP has completed TOT in 8 districts; while
Chhattisgarh has is yet to start IMNCI trainings in the state. Other key interventions reported
by various states being: strengthening of cold chain, home based newborn care and
alternate vaccine delivery, are quite sporadic and need considerable attention. Chhattisgarh
and Rajasthan also need to reset their IMR goal for 2012, as per national goal of < 30.

Throughout the JRM, the need for more focused attention on Child Health (CH) and
especially newborn care was quite evident. IMNCI is being taken up in about 100 districts.
The entire focus seems too centred on Immunisation and IMNCI and there is likelihood of
about 500 non-IMNCI districts and care of newborn being further neglected. An alarming
observation was the decline in ORS use rates in most states as reported by NFHS 3.

Areas of Concern

(a). As identified during the second JRM, implementation of comprehensive child health
strategies needs to accelerate at state levels, both in terms of physical and financial
progress.
(b). Much more concerted action to strengthen newborn care is needed, particularly in
states with high IMR, focusing on simple measures that can be undertaken by ANMs,
AWWs and ASHAs.
(c). Home based newborn care is still of huge importance, even with increases in
institutional deliveries, as many mothers go home after the first day.
(d). The modalities of NIHFW to take over as Nodal agency for IMNCI needs clarification
vis--vis the role of medical colleges which have been working as National training
centres till now.
(e). New policies and technical guidelines for simple measures to be adopted across the
country need to be widely disseminated with an emphasis on rapid implementation,
particularly for those areas involving non-IMNCI districts (ORS/Zinc, vitamin A, etc.).
(f). Institutional training steps for IMNCI (for both in-service and pre-service IMNCI) will
need to be complemented by efforts to support actions by programme managers at
state and district level.
(g). State and national monitoring of all child health activities needs to be strengthened,
with emphasis on monitoring processes as well as outcomes.
(h). Equity and gender concerns need to be considered with setting priorities. Gender
differential is very high.
(i). Supportive supervision needs to be strengthened.
(j). The child health budget is fragmented and should also include budgetary allocations
for routine immunisation and polio eradication.
(k). There is room for enhanced convergence with the AWW workers and centres to
provide comprehensive care for malnourished children, where they are also sick and
not fully immunised.

Agreed Actions

(a). By July 2007, finalise the operational plan for implementing and scaling up IMNCI,
including the concerns shared above.
(b). By July 2007, finalise guidelines for management of sick children including newborn,
diarrhoea and severe malnutrition for referral care at FRUs.

- 15 -

(c). By June 2007, finalise the revised diarrhoea guidelines and initiate regional
dissemination workshops.
(d). By July 2007, finalise the operational plan for revitalising and implementing a facility
based newborn care programme.
(e). By July 2007, get the requisite permissions for the Anganwadi Workers and ASHAs
to prescribe Co-trimoxazole.
(f). By July 2007, finalise the operational plan and guidelines to promote Infant and
Young Child Feeding (IYCF).
(g). By September 2007, finalise a policy for actively combating early childhood anaemia.
(h). By September 2007, finalise and disseminate operational plan for promoting Zinc as
an adjunct therapy with ORS for diarrhoea.
(i). By September 2007, include the simple measures of home based newborn care that
can be undertaken by ANMs, AWWs and ASHAs into IMNCI with the help of a
committee (to address concern b above)


6. FAMILY PLANNING

NFHS3 (2005-06) again shows wide variations for family planning indicators across states:

a. Unmet need for spacing methods ranges from 2.4 in HP to 23.2 in Meghalaya.
Other focus states with high figures include Mizoram, Jharkhand, Bihar, Nagaland
and UP, while Assam, Tripura and Uttarakhand have low figures.
b. Unmet need for terminal methods ranges from 1.8 in Andhra Pradesh to 16.4 in
Nagaland. All focus states except HP, Mizoram and Chhattisgarh have high
figures.
c. Total unmet need is the highest in Meghalaya (35.1) followed by Nagaland (26.4),
Jharkhand (23.8), Bihar (23.1) and UP (21.9).
d. Contraceptive prevalence rates for any modern method vary widely between
Tripura (17.6%) and Himachal Pradesh (71.0%). The prevalence among is high
for the FE states, low for most of the NE states, and mixed for EAG states, except
Goa with a prevalence of only 37.3%.

Comparative analysis between NFHS 2 (1998-99) and NFHS 3 (2005-06) on family planning
indicators shows that:

a. Unmet need for spacing methods has declined in all states except Jharkhand,
Goa, Haryana, and Mizoram. Among the focus states, this decline is most
marked in Manipur, Arunachal Pradesh and Nagaland.
b. Unmet need for terminal methods has also declined across most states, except
Jharkhand, Orissa, Haryana, Karnataka, Punjab, Arunachal Pradesh, Mizoram
and Nagaland.
c. CPR for any modern method has increased across all states, except for Tripura,
Meghalaya and Nagaland.
d. CPR for IUD is low across the board, but higher in NE states (highest in Tripura).
e. CPR for Oral Pills has increased in nearly all states and shows an interesting
pattern it is much higher in the eastern belt, including NE states, West Bengal
and Orissa, compared with the rest of the country.
f. CPR for condoms shows very low figures for the NE and EAG states, with slightly
higher usage in the FE states.
g. Male sterilisation acceptance has declined across the board (except for Sikkim
and Chhattisgarh). In fact, aside from Sikkim, male sterilisation acceptance in the
NE states is negligible.
h. Female sterilisation acceptance has increased in most states, but it remains poor
in the NE (except Mizoram, Arunachal Pradesh and Sikkim).

- 16 -

i. Andhra Pradesh, Karnataka, Tamil Nadu and Maharashtra each having
achieved the RCH II (2010) target of 2.1 for TFR, have more than 50% CPR for
female sterilisation (63% for Andhra Pradesh). Spacing method use in these
states is among the lowest.

Progress since 2
nd
JRM

Reduction in unmet need for limiting and spacing contraceptives, expanding contraceptive
choices, ensuring quality of care and respecting clients choices are certain key commitment
in national PIP with reference to family planning.

Since 2
nd
JRM several initiatives have been undertaken to meet these commitments. These
include revising compensation to the states so that quality contraceptive services can be
delivered. The revised Quality Assurance and Standards Manual on sterilization services
has already been printed. To operationalise the State & District Quality Assurance
Committees on sterilization services six regional dissemination workshops have been
planned to disseminate the revised Quality Assurance and Standard Manuals. One two
days workshop has already been held on 31
st
Jan and 1
st
Feb 2007. It is suggested that
similar dissemination should also take place in the states and districts to cover all providers.

In order to increase access to spacing methods, Government of India is developing a
strategy to reposition IUD services. An alternative training strategy for IUD has been
developed to improve the skills of providers and is being taken up in one district each of 12
states as a pilot project. Similarly a social franchising scheme for engaging private providers
in provision of IUD in 3 states has been worked out. It is suggested that results from pilots
proposed in three states be considered while scaling up this scheme. It is also encouraging
to note that there is more visibility for Emergency Contraception (EC) now and states are
making demands for supplies. ASHA training may also include Standard Days Method
(SDM).

Non-availability of NSV kits has been addressed with support from a development partner.
Such support may also be required in future to procure additional kits. Additionally, Zoe
models for IUD training are also being provided with DP support. Specifications on
Laparoscopes have been shared with states and states are going ahead with procurements.

A well-developed cascading training strategy has been prepared for ensuring district wise
training of NSV providers with the ultimate aim of positioning one NSV provider in each PHC.
158 District Trainers have been trained in NSV in 2005-2006 and 5 states namely Punjab,
Haryana, Uttarakhand, Rajasthan and Himachal Pradesh has been completed.

Expanding contraceptive choices remains a concern. Results of trials for monthly injectable
Cyclofem and bi-monthly injectable contraceptive Net-En are awaited. GOI will consider
including these methods in the national programme after considering the final study results.
It was suggested that experience available in the social marketing sector in introducing
DMPA might be considered in some states and could be taken up as a PPP initiative.

Areas of concern:

a. Increasing access to family planning services for addressing unmet need for both
limiting and spacing methods is critical to achieve goal of TFR of 2.1 by 2010.
Though there has been some decline in the unmet demand, and contraceptive
prevalence rate have gone up since NFHS2, there are wide variations across the
states. Unmet demand still remains unacceptably high in the high focus states.
Reports coming to MOHFW for current year suggest nearly 10 percent dip in the
number of acceptors for sterilisation services and for IUDs.

- 17 -

b. Sub district facilities are not providing sterilisation services on a regular basis.
c. States are not taking any initiative in increasing the pool of trained providers in the
districts and sub districts. Training of providers in minilap, tubal ligation, and
laparoscopic sterilisation, has not been pursued in most states.
d. States are not optimally utilising the NSV district trainers. Feedback may be
requested from these trainers to identify mechanisms for ensuring that their services
are better utilised by states.
e. Contraceptive updates TOT were conducted at the national level. There is no follow
up of similar trainings required to be conducted in the districts. Most PIPs also dont
reflect on the contraceptive updates training.
f. Quality of sterilisation services in the camps is a matter of concern. SOP for camps
as recommended in the 2nd JRM could not be finalised.
g. Concerted BCC strategy for promoting family planning methods such as emergency
contraceptive pills, Copper T 380, ECPs and NSV is not in place.
h. Existing PPP schemes aimed at providing delivery care and emergency obstetric
care services package have not been expanded to include FP services.
i. All 24X7 institutions and FRUs, witnessing quantum jump in the institutional
deliveries should also be equipped to provide family planning services as per client
choice.
j. Post partum phase is a very important entry point for provision of contraceptive
services and opportunity should be used to counsel about family planning methods
and provide services.
k. Private providers for providing FP services are not accredited in many states
l. Seasonality in provision of sterilisation services especially through camps needs to
be addressed. Invariably there is pressure in the system to achieve all ELAs
(expected levels of achievements) during the last few months of the financial year. In
such situations adherence to standards remains an issue.

Agreed Actions

a. By April 2007, MoHFW to provide guidelines to states for formulation of an IEC
strategy for promoting spacing methods such as ECPs and IUDs.
b. By June 2007, finalise SOPs for sterilisation camps and disseminate to states.
c. By next JRM, assess the feasibility of inclusion of injectable contraceptives, based on
study results, and prepare a strategy of their inclusion in the national programme.


7. ADOLESCENT AND REPRODUCTIVE SEXUAL HEALTH

Progress since 2
nd
JRM

GoI have finalised ARSH strategy and training modules for medical officers and health
workers. Adolescent health has also been included in ASHA training. One Regional
dissemination meeting was held in the month of December in Gujarat for Western states.
This has resulted in conduct of TOTs and training of service providers in the states of
Gujarat, MP, Rajasthan, Maharashtra and Goa. Others states such as UP are also planning
training programmes for service providers. Similar dissemination workshops are being
planned in other regions.

It was suggested that states going ahead with implementation of ARSH strategy should also
organise some rapid assessments to understand critical elements of success or the barriers
in utilisation of services. Other suggestions included: use university students and other
adolescents to develop messages for adolescents; NSS may be used for propagating ARSH
messages; nutrition, lifestyle, non-smoking, etc. to be also covered in services for
adolescents; convergence with AIDS Programmes should be explored.

- 18 -

Areas of Concern

(a) There is no strategy for demand generation and creating an enabling environment for
adolescents to seek services.
(b) Inter sectoral coordination especially with MHRD and MOYAS is lacking.
(c) School health programmes are being implemented to varying degrees by the states.

Agreed Actions

(a) By June07, MOHFW will develop a communication strategy and materials for ARSH
and disseminate to the states.
(b) By August07, MOHFW will incorporate indicators for ARSH into the MIES format for
monitoring progress. Guidelines for measuring these indicators to be incorporated
into the MIES format guidelines.
(c) By August07, MOHFW will work with NIHFW on mainstreaming ARSH training into
the RCH training framework.
(d) By September07, MOHFW will provide guidelines to states for school health
programmes in RCH II/NRHM PIPs for 2007-08. These will also include mechanisms
for convergence with school health activities under different programmes.


8. PROGRAM MANAGEMENT

Progress since 2
nd
JRM

The Memorandum of Association and the Rules & Regulations for the National Health
Resource Centre (NHSRC) have been finalised and the NHSRC has been registered as a
Society. The first meeting of the Governing Body will be held shortly after JRM3. This JRM
has highlighted the urgency of making the NHSRC functional to provide coordinated TA to
the States and the Centre.

The Memorandum of Understanding with MOHFW for implementation of NRHM including
RCH II has been signed by UP, Karnataka and Andaman & Nicobar. Only Delhi and
Lakshadweep are yet to do so.

The Program Management Support Group (PMSG) at the centre is fully functional. Key
activities since 2
nd
JRM include:

Preparation of a draft operating manual for planning and monitoring of RCH II
component of state NRHM PIPs; the manual has been forwarded to all the
programme divisions for comments. The manual is integrated with the existing
framework for preparation of district NRHM action plans and provides guidelines,
formats for preparation of state plans, self appraisal and holistic ((outcomes, physical
and financial) monitoring of performance including preparation of quarterly variance
analysis reports.
Analysis of SPIPs (financial allocations to various heads e.g. MH,CH, FP, BCC,
vulnerable groups, etc) for 05-06 and 06-07 has been completed and shared with all
the Programme Divisions.
A detailed TOR for design of web based information and communication system has
been prepared and forwarded to FMG and M&E for comments. The web based
system will act as a one-stop shop for all RCH II related information required by a
range of stakeholders; enable intra-communication amongst MoHFW programme
divisions, states, districts and DPs and provide a data base and monitoring reports
(both physical and financial).

- 19 -
A draft report on system for facilitating /assessing performance of SPMU/DPMU has
been prepared. The report, inter alia, focuses on HRD requirements of
SPMU/DPMU staff as well as monitoring their working conditions and effectiveness/
performance.
Summary reports on RCH II performance since start of the programme (April 1,
2005) till September 2006 has been prepared for 19 (including most of the high
focus) states has been prepared; similar reports for the other states will be prepared
by February, 2007.

While over 1300 SPMU/DPMU staff have been recruited, Uttar Pradesh and J&K are yet to
take any step in this context. Progress on training of DPMU staff could be much better: less
than 50% of staff have been trained.

Status on actions agreed in JRM-2

In order to ensure adequate understanding of the roles and responsibilities of the program
management structures and their relationship with the department of health at the state and
districts, a draft HRD manual has been prepared in consultation with the 8 EAG states.
NERRC has prepared a draft HRD manual for NE States, which is currently under
discussion.

The planned HRD strategy review for state and district program management units in HP,
J&K and Assam has not commenced primarily due to delay in recruitment.

A draft operating manual including comprehensive program performance reporting system
vis--vis the approved State PIPs, which links outcomes with strategies, activities and
expenditure from all sources including state contribution, has been prepared. The manual
will be fully operationalised by April 2007 as agreed in the 2
nd
JRM.

Areas of concern

(a). UP is yet to recruit SPMU/DPMU staff. In several states, attrition of staff, especially
accountants, is becoming an area of concern. Addressing HRD requirements of
SPMU/DPMU staff including induction, training, and performance appraisal would be
a major challenge especially in the context of attrition.
(b). MoHFW is yet to take forward the recommendations made by A F Ferguson & Co. on
organisational review of the Ministry including regional offices and the CGHS.
(c). States need to report progress against agreed milestones in their respective MoUs.

Agreed actions

(a). By March 2007, NHSRC will be made fully functional with all development partners
nominating their representatives on the advisory board, a full time director in place
and an approved business plan.
(b). By March 2007 the report by AF Ferguson & Co. on organisational review of MoHFW
will be considered by the Ministry and a decision taken on the way forward.
(c). By February 2007 the draft operating manual on planning and monitoring of RCH II
component of NRHM PIPs will be finalised and disseminated to at least some states.
The manual will also address (1) monitoring of states performance vis--vis MOU
indicators, since from next year, releases would be conditional on states achieving
milestones in MOUs (2) guidelines on how RCH II chapter in NRHM PIP would be
appraised, given crosscutting issues such as institutional arrangements, IEC, M&E,
etc. Infrastructure should be a common component across NRHM. A map/chart
denoting the components that would form part of the GOI support for RCH II and
other components of NRHM will be defined, which would bring clarity in the process

- 20 -

of assessment of the RCH II chapter of the NRHM PIP. (3) Mechanisms for
developing reporting arrangements such that total allocations and expenditures for
RCH II, from all available sources are captured for each state.
(d). By April 2007 the draft report on system for facilitating /assessing performance of
SPMU/DPMU will be finalised and disseminated to the states. The system will also
monitor arrangements for addressing (1) HR needs of the SPMU/DPMU staff/
consultants through e.g. appointing a HR professional/ consultant at state level; and
(2) attritions through e.g. states maintaining a panel of short listed candidates for
filling up positions following resignations; and identifying reasons for attrition in each
state and taking necessary corrective action.
(e). By April 2007, the contract for detailed design and implementation of the web based
information system will be awarded and work should have commenced. NRHM and
ID division needs to be incorporated.
(f). Development partners to provide technical assistance for setting up of State Health
Resource Centres.
(g). By April, 2007 set up programme management support arrangements in UP.


9. ACCESS AND EQUITY

Progress is being made towards achieving the RCH II aim of increasing access to
mainstream, basic health services by the poorest communities with the worst health
indicators. Several states have taken steps to integrate equity into the planning,
implementation and monitoring processes:

Mapping gaps: Orissa, Rajasthan and Gujarat are all examples of states that are
mapping the distribution of health facilities in order to identify gaps in coverage.
Reduction in inequities in the distribution of health staff: States such as TN,
Rajasthan, and Haryana have effectively used incentives to get ANMs and other
workers to serve in rural areas. MP has set an excellent example by funding SC/ST
and other students to study nursing; after completion of their training these women
will serve in MP for five years. This should be carefully supported, monitored and
documented.
Community involvement: Cause of death inquiries are being undertaken with
community involvement in some states such as Orissa. Chhattisgarh is promoting
community involvement in collecting human development data.
Transport: States, such as Tripura, provide free transport to all mothers while others
like MP are experimenting with schemes such as the Janani Express where patients
pay. These different schemes need to be evaluated. Rajasthans Helpline is another
example that needs evaluation and dissemination.
Increasing disabled peoples access to facilities. Gujarat has included specifications
for ramps in all new facilities.
While some states are gathering disaggregated data and using it in planning, equity
concerns should be addressed in the future State PIPs and that innovations aimed at
promoting equity needs to be properly evaluated and disseminated. The process
manual for developing State PIPs should include criteria for evaluating equity issues.

Areas of concern

(a) Most of the proposed strategies such as periodic health camps and mobile clinics are
immediate and short-term measures to improve access to the vulnerable populations.
These should be embedded within an overarching and holistic long-term strategy
defining service package, follow-up mechanisms and partner management.

- 21 -

(b) The JRM found little evidence that data is being analysed, disaggregated by SC/ST
or used to identify underserved communities or gaps in service provision. One
reason for the above could be lack of capacity at all levels and this represents an
urgent training need.
(c) The Action Plan under RCH II for the year 2006-07 shows that very few States have
included area specific proposals on Urban/Tribal Health in their State PIPs.
(d) Urban and peri-urban poor could be given much greater emphasis. Very low
expenditure has been reported on the Urban/Tribal Health components under the
RCH II PIPs for 2006-07.

Agreed Actions:

Pending from 2
nd
JRM

(a) By March 2007, the states should initiate wider dissemination of the equity aims of
RCH II to PRIs, NGOs and CBOs working with SC/ST populations. This will need to
be maintained over the next year.
(b) During June 2005, Government of India had constituted a Task Force to advise the
NRHM on Strategies for Urban Health Care. The Task Force has almost finalized
its report, which is at present under submission for seeking approval of the Ministry.
The recommendations made by the task force will be implemented, once the
Government of India takes decision regarding the same.
(c) The State and district plans for 2007-08 should ensure the following:
Map Health infrastructure and staff resources clearly identifying gaps and
disparities in service provision for vulnerable populations and strategies to
address them including prominent display of user fee exemptions for the poor.
Clear criteria for rational and fair resource allocation based on need must be
identified and disseminated widely by each state and district.
SC/ST and women PRI members should be involved in developing the DAPs and
serving on Village Health Committees and District Health Societies. Composite
Medical Index proposed by Orissa is an example of doing this.
Performance indicators must be identified to measure the extent to which,
government, NGO or PPs health facilities are inclusive and non-discriminatory to
all patients (SC/ST, BPL women and girls). These indicators and benchmarks
should be disseminated amongst NGOs and PRI members representing these
groups to facilitate Community Monitoring and reporting.
In the states with relatively high female child mortality, a gender module will be
developed, tested and included in IMNCI and training for AWWs.
Location and establishment of new ANM Training Institutions should prioritise
Blocks with high tribal and SC populations.
(d) By next JRM, states should have system in place for monitoring sex ratios at birth
and report the trends during the JRM.


10. TRAINING

Progress since 2
nd
JRM /Status on actions agreed in JRM2

Week long training programmes for state teams on DHAP are underway in collaboration with
Lal Bahadur Shastri National Academy of Administration, Mussoorie. About 130 officials
across 21 states have been trained so far. The training covers financial management,
planning process, prioritisation, etc.


- 22 -

MoHFW has initiated steps for states to assess the infrastructure and HR needs of
SIHFWs, CTIs, and RRCs and to review their CTPs and PIPs to ensure rationalized
trainings and connect them to service provision.

Supportive supervision is already incorporated in all the existing training modules developed
by MOHFW/ NIHFW. Supervisory role of LHVs is emphasized during the hands on skill
upgradation training by providing 1 week additional training, specifically on supervision.
Guidelines for immediate post training proficiency certificate norms for IST, SST, SBA &
Immunisation have already been developed by NIHFW and are being used.

GoI has decided to integrate training programmes for the NRHM components and have a
common training calendar under the Training Division. A draft document on integration of
training under NRHM has been prepared, discussed and finalized.

Areas of concern

(a). Implementation of training programmes is slow. Less than 10% of the 06-07 training
load for SBA, emergency obstetric care and immunisation have been completed (as
at January 8, 2007). The corresponding figures for life saving skills in anaesthesia,
laparoscopic sterilisation, mini-lap and MTP are better at 20%, 67%, 59% and 39%
respectively.
(b). Gender mainstreaming, as highlighted in 2
nd
JRM, needs to be incorporated in the
training programmes. Guidelines were earlier prepared and shared with the states.
Additionally, ToTs were conducted for SIHFW trainers.

Agreed Actions

(a). By April 2007, the Training Division will prepare a detailed national strategy and plan
for upscaling training across all states, involving the DPs. The plan will identify
alternative training service providers and specify roles of the Training Division,
NIHFW, NEERC and states in meeting the total training load as well as mechanisms
for monitoring progress and quality/ impact of training.
(b). The RCH II chapter of the state NRHM PIPs will set out an assessment of the
training load and strategies for meeting the requirements including strengthening of
existing DHFW facilities (DTCs/ Regional FWTCs/ HTCs, ANMTCs), private sector
participation, utilisation of AYUSH facilities, etc; emphasis will be given to addressing
the needs of the most underserved areas/ vulnerable groups in identifying training
facilities to be strengthened, identification of staff for training and subsequent
placement.
(c). By next JRM, Training Division/NIHFW will follow up on the status of gender
mainstreaming in RCH II/NRHM training taken up by states. States will report on the
steps taken in this regard during the next JRM.


11. INNOVATIONS IN SERVICE DELIVERY

Progress since 2
nd
JRM

In RCH II there has been a marked openness in pursuing a range of innovations by the
different states for improving service delivery. As noted in JRM-2 the innovations are not
limited to better performing states and are geared towards addressing key gaps in
infrastructure, staffing and staff skills, logistics and supplies, referral transport, monitoring
and demand side financing. From the state reviews it was apparent that the range of
innovations was widening.


- 23 -

During the 2
nd
JRM it had been agreed that that these innovative strategies will be
evaluated to draw lessons learnt and the findings will be used to scale-up innovations within
the state and also replicate these appropriately in other states. Some states such as Gujarat
have recently undertaken a rapid assessment of the Chiranjivi Yojana (adapted JSY in
Gujarat) and identified key technical, health systems and communication issues that need to
be looked into while scaling-up the scheme to other districts while states such as UP have
initiated the vouchers scheme for improving access to safe motherhood services through the
private providers in an operations research mode. In MP maternal and child mortality is
being tracked under the Dhanwantari Yojana for provision of comprehensive health services
including institutional deliveries. However, by and large, the Mission observed that the
innovations in various states are not adequately geared towards tracking health outcomes,
financial risk protection and client satisfaction. These are important aspects that need to be
thought through carefully while designing, implementing and monitoring these interventions.

In several states innovative approaches for ensuring the requisite compliment of staff at a
health facility are also being initiated. For example, in Kerala compulsory posting of medical
officers and specialist (Snehithan/ Snehitha doctors) is being pursed, in UP and
Chhattisgarh special incentives for better performance are being planned for staff working in
more difficult circumstances and in many states (e.g. J&K, MP, UP) vacancies are being
filled through contractual appointments. In states such as Sikkim the contractual
appointments for specialists is not working out because of the proposed remuneration.
Andhra Pradesh faced a similar problem as no doctors wanted to work in medical mobile
units, but they countered this by partnering with private medical colleges. Sharing of
experiences across states can be useful in fine-tuning strategies.

Partnerships are also being initiated for upgradation of facilities. For example, in Kerala,
Hindustan Latex Limited (HLL) is being contracted for completing upgradation of CHC to
IPHS level. In Rajasthan and Andhra Pradesh, health information helplines are being
implemented in partnership with a NGO while states such as MP are implementing an
innovative scheme called the Janani Express Yojana. for providing transport facilities to
pregnant women and others to hospitals.

MNGO scheme

The MNGO scheme appeared to have gained some momentum since the last JRM. The
TOT manual has been developed, over 300 MNGOs have been trained in RCH and the
FNGO handbook is also ready for printing. Some innovations are being undertaken under
the MNGO scheme including community based social audit in Himachal Pradesh that has
potential for being replicated to other states. To accelerate the implementation of the MNGO
scheme and improve efficiency, UP has decided to stream-line the contracting and
management of NGOs by outsourcing to 3-4 large reputed NGOs that in-turn will contract
other NGOs. The state reviews indicated that in several states the NGO services were
restricted to the government resource envelope and the states were not adapting this
scheme appropriately to accelerate the health outcomes.

The implementation of the MNGO scheme differs from state to state. In Orissa, West
Bengal, Himachal Pradesh, Gujarat and Maharashtra this seems to be much further along
while states such as Assam, Punjab, Haryana, Tamil Nadu and Karnataka, where actual
implementation is slow. have identified the MNGOs in most of the districts but the training of
the NGO workers has not yet been initiated.

Areas of concern

(a). Several areas of concern noted in the last JRM still remain partially unaddressed.
Though the approvals of MNGOs and Field proposals have become more

- 24 -

expeditious, the number of districts covered by MNGO projects has not increased
significantly. Also, adequate flexibility is not being used by the states to modify the
scheme to suit their needs.
(b). It also became apparent during this JRM that all the innovations are not adequately
captured in the PIP. For example, in Madhya Pradesh, MNGOs were implementing
several good ideas, but these were not reflected in PIP.
(c). Only eight states have state NGO coordinators. Rest of the major states need to
position State NGO Coordinator, who will also be a member of the State Health
Society.
(d). Though some of the innovative approaches are being evaluated or have plans in
place for undertaking an assessment, several of the innovations require proper
evaluation before scale-up to ensure that they are addressing critical gaps in the
programs and improving the utilization of services especially by the vulnerable
populations. The cost effectiveness and efficiency also needs to be documented
before large scale-up
(e). The sharing of the experiences of different states continues to be sub-optimal and in
many cases the states are re-inventing the wheel and not learning from other states
that have successfully implemented similar innovations. MNGO Scheme needs to be
included in all districts and State PIPs.
(f). There is a need for one Regional Resource Centres for each major state, and made
co-opted member in the State Health Society.

Agreed actions

Actions pending from last JRM

(a). By January 31, 2008 the MOHFW will document and disseminate best practices on
PPP.
(b). By January 2007, NHSRC/SHSRC will facilitate availability of contractual technical
assistance to states, and also provide support for M&E.
(c). By June 2007, formats for evaluating on-going innovation will be ready for use. The
MOHFW in collaboration with States will prepare this.
(d). By this JRM an assessment report on the progress of the MNGO scheme was to be
provided.

Other agreed actions

(e). By April 2007 undertake an independent assessment of NGO scheme in at least
some states such as Orissa and West Bengal and disseminate findings widely.
(f). While reviewing the PIPs for the next three years greater attention should be given to
ensure that the innovations are adequately captured in the PIPs and health outcomes
are clearly delineated. This should be specifically be reviewed in the context of
targeting vulnerable populations.
(g). By April 2007, MOHFW to establish a working group with DP participation to draft
guidelines for performance based contracting and contract management to assist the
states.
(h). By June 2007, MOHFW to review the salary structure for contracting specialists and
recommend competitive options to states for attracting quality specialists.
(i). By next JRM, states will undertake NGO consultations (facilitated through MNGOs)
to build in community/civil society perspectives on RCH II as a part of the programme
review.

- 25 -

12. DEMAND CREATION

Progress since 2
nd
JRM

Since the 2
nd
JRM, progress has been made in developing a framework for strengthening
intra-communication that has been recently shared with the states. Several states have
indicated interest in initiating this for creating an enabling environment for health providers in
the public health system. Centre is exploring the possibility of initiating some pilots in
collaboration with development partners.

The NRHM branding has been further strengthened and independent tracking data indicates
that NRHM was the most visible brand in government communication on TV, and health
awareness together with health and family welfare garnered the majority share. A
consumer tracking study has been initiated with USAID support that will indicate the recall
and effectiveness of the national BCC efforts.

At the centre, the focus continues to be on key thematic areas including JSY, ASHAs,
routine immunization, spacing methods, institutional delivery, breastfeeding and PNDT and
the girl child. New multi-media software has been developed in collaboration with
development partners in most of these areas. Several innovations in promoting health
messages through multiple channels have been initiated including key program messages
printed to Meghdoot postcards, printing of prescription slips for public sector providers and
institutionalization of the quarterly NRHM newsletter.

Another noteworthy action is that the monitoring of states with regard to BCC budgetary
allocations has been intensified. Integrated BCC for all NRHM components is being planned
by the IEC Division.

Some states have made significant strides in rolling out the BCC activities. For example, in
Assam the BCC capacities of the state are being strengthened and media experts are in
place at the state and district level and several below the line BCC activities are being
undertaken. In MP and Haryana, efforts to pilot intra-communication efforts have been
initiated. In Chhattisgarh and Uttarakhand, BCC strategy has been finalized.

Status on actions agreed in 2
nd
JRM

Since the 2
nd
JRM, two positions have been added for addressing BCC issues related to
adolescent health and development of content. For the remaining positions envisaged in the
national PIP, the TORs have been developed, albeit, the arrangements have not yet been
put in place.

The mechanisms to support states in the development of a comprehensive and integrated
BCC strategy need to be fast tracked. However, it is important to note that in the eight EAG
states a review of the state capacities for implementing IEC activities at the state and district
level is being undertaken and will help establish a benchmark for institutional strengthening.

Organizing TA for capacity building of state counter-parts to plan, implement and monitor
BCC activities has not yet been initiated. There are plans to initiate this through regional
BCC workshops.

Areas of concern

(a). The limited capacity to implement BCC activities at the state and district level
continues to be a major constraint.

- 26 -

(b). There is lack of clarity among providers and clients about several programs
including JSY. To strengthen this, an intra-communication, efforts need to be
expanded to other states beyond MP and Haryana.
(c). Mechanisms need to be put in place to replicate successful practices such as
engagement of communities in disseminating messages in Chhattisgarh, releasing
advertisements on JSY in Assam, skits for promoting institutional deliveries in AP.
(d). Focus to be placed on community empowerment activities at the village level through
womens groups, SHGs and PRIs, and these activities reflected in district plans.
(e). Monitoring and evaluation systems for BCC activities need strengthening with
specific focus on outcomes.

Agreed actions

(a). By May 2007 the BCC unit at the national level should be fully staffed with clear
roles, responsibilities and deliverables for the staff. It is particularly key to recruit
consultants for field operations will work with the states to facilitate planning and
implementation of non-mass media BCC activities at the local level.
(b). By May 31, 2007 as per the review of state capacities for BCC, the BCC units at the
state and district levels for EAG and NE states, J&K and HP to be fully staffed with
clear roles, responsibilities and deliverables for the staff.
(c). By June 2007, regional workshops conducted for developing state BCC strategies in
collaboration with development partners. The NE workshop should be give priority.
(d). By May 2007 intra-communication model to be expanded to additional states.
(e). By April 2007, based on a comprehensive strategy, generic spots on ASHA, JSY,
spacing methods (especially IUDs and EC) and PNDT should be developed and
aired on priority.
(f). As agreed to in the 2
nd
JRM, by June 2007 strengthen the ASHA/AWW/ANM training
with inter-personnel communication skills to adequately address patient concerns
and empower patient decision-making.
(g). By March 2007 a comprehensive plan for monitoring and evaluating BCC activities to
be developed.
(h). By February 2007, issue Expressions of Interest (EOI) for hiring external agency for
content creation and media buying.
(i). By June 2007, IEC Division will prepare an integrated BCC plan for addressing all
NRHM components (including RCH) in consultation with all the programme divisions.


13. MONITORING AND EVALUATION

Progress since 2
nd
JRM/ status on actions agreed in 2
nd
JRM

NFHS3 results for 29 states and India are now available. The design of the DLHS-3 survey
has been completed and administrative approvals have been obtained; implementation is
expected to take place as per the agreed work-plan.

MOHFW has decided that the Annual Health Survey, which is being planned to be
conducted by the Registrar General of India for preparing the district health profiles, will also
include the datasets for other related departments. Disaggregated data will also be collected.
There has been some improvement in reporting from states in the new MIES format. Data on
revised formats have been received from states of Chhattisgarh, Rajasthan, Jharkhand,
Gujarat, Goa, Maharashtra, Delhi and Puducherry, although all the required data is not
available. Draft user guidelines for reporting in the new MIES format have been prepared
and circulated. The guidelines also contain information on use of MIES data for local needs.


- 27 -

There has been further progress in finalizing protocols for service quality reviews. With
support from DPs, piloting of QA protocols have been launched in six states i.e. UP,
Uttarakhand, West Bengal, Assam, Maharashtra and, Karnataka (one district each state, two
in UP). The duration of QA piloting is 24 months.

The study by IIM-A for evolving a methodology to capture management process indicators
has been completed. A pilot was undertaken in 3 EAG & 2 Non-EAG States; subsequently
the tools were refined and disseminated to all states for a self-assessment of their
management capacities on an annual basis.

The M&E Division has received administrative approval for upgradation of hardware and
software. Implementation should lead to improved management reporting.

Areas of concern

(a). Progress at the central level on community monitoring and triangulation of data has
been limited to approaching experts for a concept note. MoHFW has decided that
while Community Monitoring would be coordinated by NRHM Division, the framework
for triangulation of data will continue to be under the purview of the Statistics
Division.
(b). Considering the overall nutrition status of women and children, M&E plans for all
states should pay special attention to the monthly Village Health and Nutrition Days.
(c). Due to insufficient capacities, states may not be in a position to effectively
operationalise the new MIES format and the tools for conduct of management
reviews.
(d). As per the agreements, a mid-term review of RCH II is to be carried out 24 months
from the inception of the programme, i.e. about the time of the 4
th
JRM. The third
round of the District Household Surveys (RCH II survey) was planned to be
completed in time to inform this mid-term review on programme achievements. This
survey is yet to be started.
(e). Consistency between different schemes such as JSY in capturing disaggregated
data to be developed (e.g. whether SC/ST or BPL. Studies have indicated that
SC/ST status is a better proxy indicator of poverty).

Agreed Actions

(a) By May 2007, evolve a framework for triangulation of data on use of essential RCH
services, and within two months thereafter, initiate a pilot.
(b) By March 2007, reactivate the M&E Working Group and start process for contracting
services for concurrent evaluation.
(c) By April 30, 2007 organize regional workshops to train state level staff in
operationalising the new MIES format.
(d) By May 2007, MOHFW will review IDSP in keeping in view the information
requirements of NRHM / RCH II. The second phase of IDSP will fulfil all the
information requirements of MOHFW.
(e) By mid-term review, results of DLHS-3 survey to be made available.


14. PROCUREMENT

Progress since 2
nd
JRM

Since the 2
nd
JRM, some progress has been made in implementation of the agreed actions
to improve procurement arrangements. Crown Agents, the consultant working on capacity
building for EPW, has:

- 28 -
Completed the recruitment of six full time staff and also prepared a draft IT strategy
and a draft procurement manual
Put in place an arrangement to provide oversight to all the procurement being
handled by EPW
Made progress in modifying the compendium of technical specifications of equipment
prepared by EPW to make it more user-friendly.

However, there has been notable delays in other areas. MoHFW has signed a MoU with
United Nations Office for Project Services (UNOPS) for acting as the procurement agent but
the Agreement in the World Banks standard format is yet to be executed. Actions are yet to
be taken to undertake the procurement reviews to be conducted (by centre and states) for
the year 2005-2006. Until these reviews are completed IDA would be unable to finance any
share of expenditure for this year.

The EPW is working on its business plan, a draft of which was shared with the DPs. The
DPs welcomed the proposal to expand the EPW by adding two more Directors and other
staff. This proposal for new posts is yet to be cleared by the Government.

The Banks team made a presentation for providing inputs to MoHFW for a proposed anti-
fraud and corruption software. The roadmap for moving to e-procurement was also
discussed in view of the directives issued by Ministry of Finance asking all the Ministries to
prepare their e-procurement strategies.

Areas of concern:

(a) Actions are yet to be initiated on the procurement audits to be conducted by the
centre and states for the year 2005-06 (as per the clause 8.01 of the Development
Credit Agreement). If the procurement audits are to be conducted as part of the
financial audit, MoHFW needs to share the procurement guidelines and procurement
arrangements for the project with the auditors (Comptroller and Auditor
General/Auditor General (CAG/AG) and statutory auditors for state health societies).
The procurement audit TORs are yet to be shared with DPs. It should be noted that
these audits are an agreed pre-condition for IDA financing of expenditure incurred
during 2005-06 and subsequent years.
(b) Ensuring the continuation of the key staff in EPW continues to be a major challenge.
While all the three director level posts have been staffed, it is of concern that since
the 2
nd
JRM, the Joint Secretary (JS) and the Director, Supplies Social Marketing
(SSM) have been moved out of EPW and that the replacement for the JS is yet to be
identified. It was informed that the present incumbent of the Director (SSM) post is
also being transferred.
(c) Dissemination to all states of the procurement guidelines and agreed procurement
arrangements for RCH II need urgent attention in view of the deviations observed in
the state Audit reports submitted to the Bank.
(d) The workshops proposed for the capacity building of drug inspectors for effective
implementation of revised schedule M with technical notes are yet to be organized.
(e) The expressions of interest received for hiring of consultant for Quality and Quantity
Review are yet to be evaluated.
(f) The data regarding the contracts issued by the states and districts are yet to be
compiled by EPW. This should be given priority as the Bank is in an advanced stage
of hiring the consultant for post review of the contract.
(g) The procurement plan for 2006-07 and 2007-08 needs updating in view of the delay
in finalizing appointment of procurement agent (UNOPS). MoHFW also needs to take
a stand on the appointment of professional procurement agent to take over after the
expiry of the proposed agreement with UNOPS.

- 29 -
(h) The first market survey for pharmaceuticals has been completed. However, EPW is
yet to initiate the action on computerization of the data collected and start using the
data for taking the procurement decisions.
(i) The procurement capacity building of the states and monitoring of the procurement
handled by the states are yet to be addressed.
(j) While some of the states have procured RCH drugs/kits etc. out of the funds
extended by MoHFW (outside the pool) for 2005-6 and 2006-07, adequate supplies
are not available in a large number of states. Hence, expediting the signing of the
agreement with UNOPS and beginning the procurement at MoHFW level is vital for
the success of the RCH II.

Agreed actions:

(a) Submit the procurement audit reports for the year 2005-06 to enable IDA to disburse
their share against the eligible expenditure incurred. The TORs for conducting
procurement audits will be shared, in advance with the DPs.
(b) By February 28, 2007, complete signing of the agreement with UNOPS so that the
procurement process may be initiated at the earliest.
(c) All staffing in EPW will be completed. Also, the possibility of having dedicated
contract staff (funded by non-pooling partners) for monitoring the GAAP/agreed
procurement arrangement implementation, monitoring the procurement carried out by
the states, capacity building of states, etc. should be explored
(d) By next JRM, share the progress on GAAP including: (i) provide the list of the
companies to whom GMP certification have been issued after the joint inspection by
centre, state and independent experts; (ii) Status of procurement monitoring and
compliant database; and (iii) incorporation of the GAAP in the NPIP.
(e) As part of the Health Management Information System (HMIS) being developed by
MoHFW, develop the system for entering the contract data which will be used for: (i)
for sampling for post review; (ii) for running fraud detection software; and, (iii) for
taking management decisions (e.g. procurement delays, total value of contracts
issued etc.) by MoHFW. Till this system is developed, the data may be collected in
the excel sheet shared with EPW. The details of contracts issued by EPW, states
and districts are to be provided by MoHFW to the pooling partners by March 15,
2007.
(f) By March 31, 2007, complete the computerization of the market survey data and the
compliant database with the aim to integrate these with HMIS at later stage.
(g) By February 28, 2007, share the draft TOR for engaging Institute of Public Auditors
of India (IPAI) (who will be carrying out a procurement review as part of management
audit for U.P., Bihar, Assam, Kerala and TN) with the DPs.
(h) By March 31, 2007 share a copy of the report on the review of procurement capacity
and development work to the pooling partners.
(i) MoHFW to share the procurement guidelines/ agreed procurement arrangements
with states by March 15, 2007 and request the states to disseminate the same to
district level. MoHFW to also prepare organogram for state procurement units and
share the same with pooling partners by April 30, 2007.
(j) MoHFW to complete the evaluation of Expressions of Interest received for the
assignment of Quality and Quantity Review by February 28, 2007


15. FINANCIAL MANAGEMENT

Progress since 2
nd
JRM
Progress achieved since the 2
nd
JRM includes (a) re-enforcement by FMG of the need for
correct and uniform financial reporting of expenditures in line with stated accounting policies

- 30 -

in the FM Manual; 20 states are sending their Financial Management Reports (FMRs) on
time; (b) MOHFW decision to support an accountant at all PHCs; (c) review and circulation
of comments by FMG on FMR for the six month period ended September 30, 2006; (d)
outsourcing of management audit to IPAI; (e) initiation of concurrent internal audit of districts
and sub districts in Madhya Pradesh.

Areas of concern

(a). Finance staffing and Training: Pursuant to the mandate/ responsibility of the FMG
being extended to all the projects (including disease control projects) under NRHM,
the MOHFW has sanctioned additional posts of regular government staff to the FMG.
The mission noted that only 3 qualified consultants are in place of which two had
short tenure appointments. Further, following MOHFW decision to have qualified staff
in all the States and Districts, about 650 finance staff have to be recruited out of
which about 400 are now in place. The above staff will need to be recruited and
trained.
(b). Quality of the FMR and alignment with the PIP/AWPs: The reporting heads in the
FMR and the PIP/AWP are not aligned resulting in limitations in carrying out a
meaningful monitoring of the approved plan verses the actual progress.
(c). Uniformity and consistency in accounting: Expenditure by activities have not been
reported by some states (e.g. Orissa, Madhya Pradesh), transfers to sub-district units
are being reported as expenditures by certain states (e.g. Uttarakhand, Haryana).
FMG had already taken up the matter with the State for rectification,.
(d). Quality of financial statements, disclosures and comprehensiveness: (this is
inevitable as the unspent funds were available with the districts and they have spent
on the ongoing activities). While districts are being audited, it is not clear whether
district level financial statements are being prepared and certified by the auditors.
Since districts are legal entities (registered societies) they are also required to
prepare financial statements. In addition, district financial statements have not been
consistently consolidated (i.e. assets, advances and cash & bank balances etc) at
the State level to reflect the overall financial position of the State. This needs
verification at the State level. Some of the states, like Kerala, Jharkhand have sent
district wise financial statements. But these may not be required at the centre. In MP
for example district level financial statements were compiled but not sent to the
centre.
(e). External Audit Quality and Comprehensiveness and review by FMG: A review of the
audit reports for the year 2005-06 indicates that there is a distinct improvement in the
coverage of the audit and the quality of the management letter, however this is not
consistent across all the States (e.g. in Orissa the auditor has audited only the State
society and relied on UC from the districts- it is not clear whether the districts have
been audited by other auditors). While all the states (except one) have appointed
auditors from the short-listed panel sent by the FMG, it is not clear whether the
process of selection as provided in the FM manual (i.e. select the firm on the basis of
quality rather than least cost) has been followed. In addition the level of audit fees
appears to be low compared to the extent of the work required and the completion
and submission of reports is substantially delayed.
(f). Internal control & system of internal audit the management letters from the external
auditors indicate the need to significantly strengthen internal control especially at the
districts, sub- districts and below.

Agreed Actions

(a). By May 2007, MoHFW will complete recruitment of finance staff, for FMG. It is critical
to have a stable core team of at least 4 qualified consultants in the FMG over the

- 31 -

next 2 to 3 years to support the Director (NRHM Finance) in implementing the
reform plan
(b). By September 2007 states to complete recruitment of remaining finance staff at state
and district levels. If necessary, MoHFW to facilitate recruitment. The recruitment
falls in the domain of State Government, however, the MOHFW should impress upon
the States to move urgently on this matter.
(c). By April 15, 2007 FMG to develop a structured training plan which should include
time lines, development of training modules for various levels of staff and
identification of resource persons (individuals/ institutes) and complete training by
December 31, 2007
(d). By March 31, 2007, strengthen quality of FMR and review process as follows: (a)
review and align the reporting heads in FMR with the PIP and AWP heads in
consultation with PMSG and provide guidelines for accounting and classification of
the expenditures; (b) review the FMR for the quarter ended December 31, 2006 to
ensure that transfers are not reported as expenditures and take actions to rectify
excess reporting by States, if any (c) institute a system of communicating the FMR
review comments to the States especially activities not envisaged under RCH II in
State plans (d) require central level units to report quarterly expenditures to the FMG
(e). Reporting the expenditure on contracts above the threshold limits is domain involving
empowered procurement wing or procurement division. The agreed financial
reporting formats do not have any systems in place for reporting on procurement
contracts as to whether NCB or ICB thresholds were crossed or not? This should be
finalized by World Bank in consultation with Empowered Procurement Wing of the
Ministry.
(f). By March 31, 2007 improve uniformity and consistency in accounting as follows: (a)
along-with the proposed formats for financial statements also circulate the accounting
policies and disclosures required in the notes to accounts as provided in the FM
manual; (b) review the chart of accounts for consistency with the AWP and provide
guidelines on expenditure booking; (c) develop and implement a pilot for roll out of
TALLY accounting package in the pilot State and Districts units.
(g). By March 2007 strengthen quality of financial statements, disclosures and
comprehensiveness by advising states to (as in the case of RNTCP): (i) first prepare
separate audited financial statements for each district and the State Society and (ii)
based on these a consolidated audited financial statement for the project covering
the State and the Districts be prepared.
(h). By May 2007 strengthen external audit quality and comprehensiveness and review
by FMG as follows: (a) the TOR for external audit and audit opinion format be
amended to specifically require the auditors to opine on the consolidated financial
statements of the State and districts; (b) the FMG should review whether the process
adopted for selection of auditors by the States is in line with the FM manual (i.e.
quality based rather than cost based); (c) in order to ensure timeliness consider re-
appointing the same auditors for a period of 3 years, in States where performance is
rated satisfactory by the FMG; and, (d) joint audit be appointed in large States with
clear allocation of districts and sub- districts and joint responsibility for the
consolidated financial statements of states and districts.
(i). By April 2007, strengthen internal control & institute a system of internal audit as
follows (a) a system of concurrent internal audit is extended to all the major States
and started at the district and sub-district level; and (b) a specific TOR will be
prepared and circulated by the FMG (along-with appointment process and reporting
format).






- 32 -

16. NE DIVISION / NE-RRC

Progress

NE-RRC was set up to provide technical assistance to the NE states for all NRHM activities.
Headed by a Director, it currently has 9 consultants in areas of Public health, Finance,
Procurement, Civil and architecture, Community mobilization and HMIS, besides 6 State
Facilitators at state HQ (except Nagaland, Tripura).

NE-RRC assisted the states in setting up of SPMSUs & DPMSUs. All states except Mizoram
have set up their SPMSUs, and the state programme managers have undergone training.
Out of 87 districts, 74 have DPMSUs in place. District programme managers have been
trained, while the district accounts managers have been oriented on financial procedures
and use of TALLY software. Data assistants from 5 states and statistical assistants from 2
states have been trained on the new MIES formats.

Out of 33,000 ASHAs required for the NE states, 27275 have been recruited. Training of
master trainers is progressing in all states. NE-RRC is also facilitating skills based trainings
like SBA and anaesthesia. Four training centres for anaesthesia training have been
established: 3 in medical colleges in Assam and 1 at RIMS, Imphal.

NE-RRC facilitated the preparation of RCH-II PIPs for 06-07. It is also facilitating NE States
in implementation of NRHM activities, submission of reports, procurement procedures,
developing proposals for BCC and HMIS, and coordination of the activities on immunization.

Areas of concern

(a). JRM3 field visit noted that DPMSU staff needed re-orientation and greater clarity
about their roles and responsibilities.

Agreed Actions

(a). By April 2007, NERRC will coordinate an orientation programme, with MOHFW
officers, for DPMSU staff from all NE states.


The implementation status of actions agreed to in the 2
nd
JRM is provided in Annex D.
Further details regarding Financial Management are provided in Annex E. Reports on
performance of each state in various functional areas together with suggested actions are
detailed in Annex F.












ANNEX - A

JRM 3 PROCESS MANUAL

- 33 -






















PMSG, DONOR COORDINATION DIVISION
MINISTRY OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF INDIA





January - February 2007


JOINT REVIEW OF RCH II

(GOVERNMENT OF INDIA, STATE
GOVERNMENTS AND
DEVELOPMENT PARTNERS)








PROCESS MANUAL

- 34 -
INTRODUCTION

RCH II was launched in April 2005 in all states of the country. The programme envisages
delivery of evidence-based package of services along with strengthening institutional
capacities for achieving National Population Policy and NRHM goals.

This manual details the structures and processes to be adopted during the third Joint Review
(JRM3) of RCH II scheduled for January February 2007. All 35 states and Union Territories
as well as the Programme Divisions will be covered in the review.

JRM 3 primarily seeks to review:
1. The extent to which evidence based strategies have been adopted by the states to
reduce MMR, IMR and TFR
2. Implementation progress / bottlenecks and
3. Efficacy of the monitoring system at state and district levels

with emphasis on programme management arrangements and institutional strategies (the
former were envisaged to be in place by April 1, 2005 and the latter substantially
implemented by March, 2006).

GOI, State Governments and the Development Partners will participate in this review. The
terms of reference for JRM 3 has been provided in Annex 1.
.
DESIGN

The review will have the following components:

Pre Mission

1. Pre Mission Activities
a. Review of summary reports on RCH II performance of High Focus states since start
of the programme (April 1, 2005)
b. Compilation of RCH II process & Intermediate Indicators by ALL states.
c. Completion of Program Management Unit (PMU) Feedback form by the 18 High
Focus states.
d. Completion of Monitoring & Evaluation Capacity Assessment Checklist by ALL states
e. Action taken report on JRM2 by the MOHFW and all States
2. Intensive Programme performance review in 3 High Focus states, namely Uttar Pradesh,
Madhya Pradesh, and Tripura including GOI/Donor Partners visits to the states and
districts
3. Review of report of National Consultation with Civil Society on community empowerment
and community involvement in RCH II/NRHM (proposed).

Mission

1. National Level programme review
a. Review of the progress of Programme divisions as per the logframe of the National
PIP

- 35 -
b. Review of the progress on work plans of RCH-II PIPs for all states and UTs

2. Dissemination /experience sharing meeting


In the following paragraphs an attempt has been made to spell out processes and activities
to be followed by the participating mission members during the pre JRM and Mission phase.

1. Pre Mission Activities

a. Review of summary reports on RCH II performance of High Focus states since start
of the programme (April 1, 2005)

Summary reports of performance of UP, MP, Tripura and other states will be
provided to the JRM members prior to the state visits. These reports provide an
assessment of the performance of each state based on the:
Latest available survey data on outcomes - NFHS 3, SRS 2005 (data for 2005
for large states and 2003-05 for small states), and SRS 2001-03 for MMR.
Respective PIPs especially the extent to which evidence based strategies
have been incorporated and funds allocated
Physical progress as reported at JRM 1 and 2 vis--vis workplans.
Financial expenditure (based on FMRs for 05-06 and the six month period
ending September 06)
Subsequently key areas of improvement for each state have been identified.
These reports will form a part of the basis for discussions during the state visits and
state reviews in Delhi.

b. Completion of RCH II process & Intermediate Indicators datasets by ALL states

The RCH II National PIP refers to 13 process indicators for the purpose of monitoring
the programme at the national level. Additional agreed Intermediate indicators have
been developed. It is acknowledged that data for some of the process indicators may
not be available with the state governments. However, the intermediate indicators
can be captured through the state MIS.

The datasets along with the definition of indicators and sources of information are
appended as Annex 2 and 3. A team of GOI and DPs will analyze the datasets
received from the states. These datasets will constitute an integral part of the JRM3
Aide Memoire and subsequently provide inputs for updating the state performance
reports. Additionally, the states may also provide the latest MIES report for the
quarter October December 2006 and the monthly reports for the same period, at
the time of the state reviews.

c. Completion of PMU Feedback Form by the 18 NRHM high focus states

Programme Management Support Units (PMUs) at State and district levels are seen
as a major initiative towards improving management of RCH II/NRHM. The
Development Credit Agreement for RCH II signed between GoI and the International
Development Association also stipulates the need to sustain and strengthen newly
created programme management arrangements. This questionnaire (attached at

- 36 -
Annex 4) will enable a consolidated assessment of performance of PMUs/ DPMUs
and provide a basis for facilitating improvement in their performance. The analysis of
these forms will constitute an integral part of the JRM3 Aide Memoire.

d. Completion of Monitoring & Evaluation Capacity Assessment Checklist by ALL states

The new MIES format developed for monitoring under NRHM was sent to the states
in August 2006. With the emphasis on outcomes under RCH II, it is essential to
assess the M&E capacities in the states to report on the new formats and identify
areas for strengthening. The checklist (attached at Annex 5) looks at institutional and
infrastructure arrangements for M&E in the states. This will also assist the states
while designing their PIPs for 2007-10. The results of these checklists will constitute
an integral part of JRM3 Aide Memoire..


2. Intensive Programme performance review in Madhya Pradesh, Uttar Pradesh, and
Tripura

a. Government of India/ Development Partners visits to state and districts

State Health & Family Welfare Secretaries of Gujarat, West Bengal and Tamil Nadu
will be requested to join the Mission while taking up field visits in Uttar Pradesh,
Tripura and Madhya Pradesh respectively.

As per the terms of reference, the main focus of these visits will be as follows:

Quality of state and district PIPs
Internal consistency between situation analysis, key issues, strategies, work plan
and costs
Extent to which strategies (maternal, child health, family planning, institutions
including BCC, HMIS, logistics, etc.) are evidence based
Process of preparation and approval of PIPs including mechanisms for
incorporating perspectives of vulnerable groups and approach to consolidation of
district plans into state PIP
Resource allocation criteria e.g. between rural and urban, across districts,
vulnerable groups and between maternal, child health and family planning, BCC,
etc
Monitoring system vis--vis the plan including for tracking access to services by
vulnerable groups, especially SC/ST/adolescents and women

Implementation bottlenecks (state and districts)

(focus on activities in the work plan in the areas of e.g. programme management,
institutional mechanisms, maternal & child health, family planning, innovations, financial
management etc)
Reasons for slow pace of implementation:
- Inadequate delegation of powers, cumbersome procedures, financial
bottlenecks, etc.
- Weak programme management structures (state and district health missions
and societies, SPMU/DPMU,

- 37 -
- Inadequate mechanisms for intersectoral convergence / coordination
- Others
Quality of RCH II work carried out including
- Appropriateness of proposed strategies for service delivery, HMIS, BCC,
training etc. in the implementation plan for improved use of RCH services.
- Ability of the key program staff to understand and implement the minimum
service standards recommended for various RCH II technical interventions
including training of staff in emergency obstetric care, newborn care,
expanding contraceptive options and access and in adolescent health
- Ability of the key program staff to understand and implement minimum
physical standards for providing acceptable quality services in strengthening
of 24x7 PHCs and operationalisation of FRUs,).
- Appropriateness of proposed strategies for Public Private Partnerships, and
other innovations in improving delivery of RCH services.
- Quality of program monitoring and financial reporting including audited
statements
Pro poor focus (in e.g. allocation of resources, training and placement of staff in
worse off districts/ blocks, prioritisation of technical interventions / facilities for
upgradation, etc)

Monitoring system at state and district levels
Reporting (physical progress and expenditure) including variance analysis
Implementation of new MIES format; disaggregated data to reflect equity
principles, especially improved use of essential RCH services by SC/ST groups.
Community based monitoring and triangulation of data
Extent to which monitoring data is being used by Programme Managers to realign
programmes and re-allocate resources to expand outreach and coverage
Each State team will generate a brief (say, 4-5 page) report after completion of the state
including district visits.

Field Visits to Identified districts
It is proposed to conduct field visits to identified districts (two districts per state).
Preferably the districts should be chosen covering one well performing district and one
from the 150 backward districts issued by the Planning Commission in 2004 (Refer
Planning Commission Classification of List of Backward Districts).
These districts will be selected before the commencement of the visit by the GOI
representative leading the team in consultation with the State Government.

The facilities in each district to be visited during the review mission will be as follows:
a. At least 2 FRUs (functioning / being upgraded from CHCs)
b. At least 2 PHCs offering 24 hour services (functioning / being upgraded)
c. 2 Sub Centres
d. District Hospital (cover teaching hospital if it plays the role of district hospital)


- 38 -
These facilities will be decided by review team for the district in consultation with district
programme managers. At least one facility of each type should be a well performing
facility, in order to obtain an assessment of the states benchmark on quality and
range of services.

At the sub-centres being visited, the Mother NGO of the district may be directed to
ensure that women from vulnerable groups are invited for focus group
discussions.

Each State team will be led by GOI and will include three representatives from
Government of India, representatives from the DPs, one State Health & Family Welfare
Secretary from a guest state (see above), and representatives from concerned State
Government.

Following programme of work is suggested for the State visits:

It is suggested that the states may designate the state programme manager as the nodal
officer to coordinate with team so that the review of the programme can be undertaken in
an organised manner.

The visiting team members, to standardize the discussions and information gathering
across Districts and States, will use a set of checklists. These are:
A. Checklist for discussions with state and district level programme managers
B. FGD Guide for Women from VGs at Sub centre village
C. Facility observation checklist
D. Monitoring and Evaluation checklist
Checklist A will facilitate an assessment of quality of state / district PIPs, implementation
bottlenecks and system for programme monitoring. Checklist B and C will provide an
assessment of quality of services and perception of target groups. Checklist D attempts
to capture capacity/ progress in implementation of the MIES format. These checklists are
attached at Annex 6 of this document.

DAY 1 & 2 Briefing meeting at state HQ. Discussions with senior functionaries, state
nodal officer and selection of districts. Discussions with the SPMU staff /
State Demographer.

DAY 3 & 4 Field Visit District HQ for discussion with CMHO, district programme
manager, and other programme officers on the district planning process
of NRHM and RCH II; District Hospital, 2 FRUs, 2 PHCs offering 24 hr
services, and 2 sub centres

DAY 5 Meeting with Mother NGOs, Field NGOs, and other NGOs working in
RCH related activities
Debriefing with state programme managers and finalisation of the
presentation for the National Level Review

- 39 -
Each State team will prepare a State report based on discussions held during the debriefing
meeting at the State level. Every attempt should be made to identify a few key
recommendations, which should be discussed and agreed together with an action plan for
implementation.

SCHEDULE FOR PRE- JRM STATE VISITS

Pre-visit Briefing of Teams
Date: Thursday, January 11, 2007
Venue: 249, A, Committee Room, Nirman Bhawan, New Delhi
Time: 3:00 5:00 PM

Visits
States Teams Dates GoI Officers
Madhya
Pradesh
GoI + GTZ + DFID +
UNFPA + one State
Health Secretary
15-19 January,
2007 (Monday to
Friday)
*Dir (MH/Stat), Dir
(RCH Finance),
AC (MH)
Uttar Pradesh GoI + WB + USAID +
UNICEF + one State
Health Secretary
15-19 January,
2007 (Monday to
Friday)
*Dir (Stat), Dir (IFD),
AC (CH)
Tripura GoI + EC + WHO + JICA
+ one State Health
Secretary
15-19 January,
2007 (Monday to
Friday)
Dy. Dir (DC), FMG
representative,
AC (Trg) *

* Team Leader


3. Reviews at National Level

The national review will be spread over two parts.

Part One: Review of MoHFW Programme Divisions

As programme performance in the states depends on the overarching support for the
programme delivery at the national level, it is proposed to organise intensive review of the
programme divisions at MoHFW. Programme divisions will present progress on the work
plan, key bottlenecks and proposed correctional measures. Status on priority agreed
actions at JRM2 should be highlighted. Areas to be emphasised by programme divisions
should be in accordance with the log frame in the National PIP and should also include
(wherever relevant):

A. MATERNAL HEALTH:
- Skilled Birth Attendance at Birth
i. Progress in training
ii. Procurement of drug kits
- Emergency Obstetric Care
i. Implementation status for Skill up gradation for management of obstetric
complications
ii. Training of doctors in EmOC and Anaesthesia in states

- 40 -
- Guidelines for RTI/STI management
- JSY Implementation
- Any models on PPP
- Issues identified in the Last JRM

B. CHILD HEALTH:
- Progress on IMNCI
- Home based New Born Care
- Essential Newborn Care (Facility based)
- Progress on Immunisation / vitamin A supplementation
- Progress on Infant and Young Child Feeding
- Progress on ORT / Pneumonia (ARI)
- Any models on PPP
- Issues identified in the last JRM

C. FAMILY PLANNING:
- Upgradation of contraceptives standards
- QA guidelines dissemination
- Providing safety insurance cover for providers
- Any models on PPP
- Issues identified in the last JRM

D. BCC
- Status of BCC unit at national level
- Progress on TA to States for developing BCC strategy and plans
- Any models on PPP

E. ARSH
- Follow up on Implementation Guide
- Follow up on training packages
- Any models on PPP

F. Infection Management and Environment Plan / IMEP
- Policy framework document and facility level operational guidelines status
- Dissemination strategy agreed including (a) communication to states to integrate
IMEP plans in RCH II PIP and (b) separate communication to mission
directorates to link it to IPHS
- Training plan for operationalising IMEP guidelines at facility level finalised

G. NGOs
- MNGOs, FNGOs funded and number of proposals sanctioned
- Capacity building plans
- Assessment of NGO scheme
- Issues identified in the last JRM

H. TRAINING
- Assessment of training infrastructure

- 41 -
- Training Guidelines for the states
- Issues identified in the last JRM

I. M&E
- Status of M&E Working Group
- Operationalisation of revised monitoring format
- Progress on piloting of Management Assessment Methodology
- Progress on piloting of Quality Assurance.
- Issues identified in the last JRM

Availability of Information through MIS on following indicators:
- % of districts not having at least one month stock of critical inputs
- % of sampled outreach sessions where guidelines for AD syringe use and safe
disposal is followed
- % of 24 hr PHCs conducting more than 10 deliveries per month
- % of upgraded FRUs offering 24hr. emergency obstetric care
- % of deliveries by SBAs - total and SC/ST
- % of deliveries in public health institutions- total and SC/ST population
- % achievement of planned measles coverage among total and SC/ST population

J. NORTH EAST DIVISION / NE-RRC
- Activities of NE-RRC
TA to NE States
Capacity Building activities

K. PROCUREMENT
- Draft Procurement Manual shared
- Empowered Procurement Wing business plan
- Status of Procurement Agency for urgent procurement needs
- Status of procurement capacity assessment & strengthening state capacity
- Status of GMP Implementation
- Local functional experts appointed and counterparts from MOHFW identified
- Skill mapping and Training Needs Assessment conducted
- Issues identified in last JRM

L. PROGRAMME MANAGEMENT ARRANGEMENTS
- Status on SPMUs/ DPMUs, training status
- Issues identified in the last JRM

M. TECHNICAL ASSISTANCE ARRANGEMENTS
- Status on NHSRC/SHRCs
- Update on NHSRC management arrangements

N. FINANCIAL MANAGEMENT
- Staffing: Critical FM Staff in position and reasons for vacancies (if any) including
proposed strategies to fill vacancies (Central FMG, State level Finance &
Accounts Personnel, District level Finance Accounts Personnel). Integration of
finance consultants with program staff.

- 42 -
- Delegation of financial powers: To program managers at state, district and
PHC levels.
- Training status: Central, State and District finance staff
- Financial Reports: Timely submission of financial reports by districts (monthly)
and states (quarterly)
- Audits: Status of audit (a) internal (district to be done by state finance consultant
and state by FMG on a sample basis) and (b) external (CAG approved Chartered
Accountant). Audit report for FY 2005-06, which is due by September 2006.
Action taken report on Audit Observations.

Part Two: Review of all states

All States are to be covered for national level review. The main purpose of this national level
review is to assess pace of implementation, analyse implementation bottlenecks, and
identify corrective measures including technical assistance requirements if any.

At the time of the state reviews in Delhi, all states/UTs must bring the completed data
sets in Annexes 2, 3 and 5. In addition, high focus states should also bring the
completed data set in Annex 4.

Following process is suggested for the national review of states:
Each State will make a presentation in ideally, less than 10 slides spread over 20
minutes. The structure of the presentation will be along the workplan and would cover
the physical along with financial progress in work against the approved activities of the
quarter ending December 2006, budget allocation and expenditure of each of the
activities. A variance analysis highlighting activity-wise reasons for delay against the
quarterly plan and remedial actions undertaken/ proposed is essential. The format
provided in Annex 7 will provide the basis for preparing a variance analysis.
The states where the pilot of Quality Assurance has been recently launched (UP,
Uttaranchal, Assam, Maharashtra, Karnataka, and West Bengal), will also report on its
status.
All states should also report on delegation of financial powers to program managers at
state, district and PHC levels, during their state presentations.
UP, MP and Tripura should ensure that key observations from the mission reports are
also incorporated in the respective state presentation.
As in the last JRM, a ranking of states will be made on basis of information in the
datasets. The methodology for the ranking is attached at Annex 8.


- 43 -
National Review (Phase I) January 23-25, 2007
Venue: 249, A, Committee Room, Nirman Bhawan, New Delhi
Date Session Time Program Div.
Forenoon 11.00 a.m. to
1.00 p.m.
(i) Programme Management / DC
(ii) Procurement
Lunch 1.00 p.m. to 2.00 p.m.
23
rd
Jan, 2007
Tuesday
Afternoon 2.00 p.m. to
5.30 p.m.
(iii) Financial Management
(iv) Monitoring and Evaluation
(v) IEC
(vi) ARSH
Forenoon 10.30 a.m. to
1.30 p.m.
(vii) Maternal Health
(viii) Child Health
(ix) Family Planning
Lunch 1.30 p.m. to 2.30 p.m.
24
th
Jan, 2007
Wednesday
Afternoon 2.30 p.m. to
5.30 p.m.
(x) Training
(xi) NGO
(xii) North East Division
25th Jan, 2007
Thursday
Forenoon 10:30 a.m. to
1:30 p.m.
Presentations of JRM Field Visits to
Madhya Pradesh
Uttar Pradesh
Tripura

National level Review of States (Phase II) 29
th
January to 5
nd
February 2007
Venue: 249, A, Committee Room, Nirman Bhawan, New Delhi
Date Time States
29
th
January, 2007
Monday
10.00 a.m. to
5.30 p.m.
Bihar, West Bengal, Karnataka, Delhi, Goa
31
st
January, 2007
Wednesday
10.00 a.m. to
5.30 p.m.
Gujarat, Orissa, Rajasthan, Andhra Pradesh, Kerala,
Uttar Pradesh
1
st
February, 2007
Thursday
10.00 a.m. to
5.30 p.m.
Madhya Pradesh, Chhattisgarh, Jammu & Kashmir,
Himachal Pradesh, Punjab, Haryana
2
nd
February, 2007
Friday
10.00 a.m. to
6.00 p.m.
Assam, Arunachal Pradesh, Manipur, Meghalaya,
Mizoram, Nagaland, Sikkim, Tripura
5
th
February, 2007
Monday
10.00 a.m. to
5.30 p.m.
Andaman & Nicobar, Lakshadweep, Puducherry,
Daman & Diu, Dadra & Nagar Haveli, Chandigarh,
Maharashtra, Uttarakhand, Tamil Nadu, Jharkhand


- 44 -
4. Dissemination Workshop
Venue: To be finalised
Date: To be finalised

Detailed agenda of this meeting will be made available at a later date. It is proposed to utilize
the opportunity for sharing experiences from good practices / innovations taken up by the
states.

Follow up Mechanisms

The state-specific recommendations emerging out of the national -level review meeting will
have to be followed up during the ensuing six months. It is suggested that the programme
management support unit will provide necessary support for initiating actions on
implementation of the recommendations. The subsequent reviews will take into cognizance,
actions initiated on the earlier recommendations.


















ANNEX 1

TOR FOR JOINT REVIEW MISSION
January February 2007

- 45 -
ANNEX 1

REPRODUCTIVE AND CHILD HEALTH, PHASE II

TERMS OF REFERENCE FOR JOINT REVIEW MISSION
January February 2007

BACKGROUND

Reproductive and Child Health, Phase II (RCH II) is a comprehensive sector wide flagship
programme, under the bigger umbrella of the Government of Indias (GoI) National Rural
Health Mission (NRHM), to deliver the RCH II targets for reduction of maternal and infant
mortality and total fertility rates. RCH II aims to reduce social and geographical disparities in
access and utilisation of quality reproductive and child health services. Launched in April
2005 in partnership with the state governments, it is consistent with GoIs National
Population Policy-2000, the National Health Policy-2001 and the Millennium Development
Goals.

The design of RCH II builds on the lessons learnt from RCH-I. The major points of departure
in the second phase are:
Ensuring a more explicit pro-poor focus
Evolving a shared vision and a common programme covering the entire family
welfare sector, the Sector Wide Approach (SWAp)
Focusing on results (outcomes rather than inputs)
Using evidence to prioritize interventions and shift resources to where the health
outcomes are worst and the need is greatest
Moving away from top down to a bottom up planning approach that gives flexibility
for the states to evolve programmes based on their contextual needs.
Introducing concepts of performance based funding
Encouraging innovative approaches, including partnerships with private sector, to
improve reproductive and child health outcomes among scheduled castes and tribes
Effective communications to bring about behaviour change
Monitoring of the programme by multiple organisations (departmental reports,
independent surveys and community monitoring) to track equitable access by and
outreach to excluded groups.

RCH II is a centrally sponsored programme, implemented across the country in all the 35
States and Union Territories. GoI has identified 18 high focus states with poor socio-
demographic indicators, for enhanced financial and technical assistance to meet the 10
th

Plan goals. These are the 8 erstwhile EAG states i.e. UP, Bihar, MP, Orissa, Rajasthan,
Chhattisgarh, Jharkhand and Uttaranchal; the 7 North East states, Sikkim, Himachal
Pradesh and Jammu & Kashmir.

RCH II is largely financed by GoI with support from DFID, World Bank and UNFPA, UNICEF,
WHO, EC, USAID, GTZ and JICA. A Memorandum of understanding between the GoI and
Development Partners (DP) is being put in place to guide this partnership.


- 46 -
A Joint Review Mission (JRM) for RCH II, led by GoI, with support and participation from
DPs will take place twice a year in January and July. Two JRMs have been carried out so far
i.e. in February-March 2006 and August-September 2006 respectively.

JRM OBJECTIVE

The overall objective of Joint Review Mission is to review progress on the shared vision and
objectives of RCH II programme as mentioned above in order to meet the MDG goals for
reducing maternal and child mortality. In the initial years progress will be measured against
key outputs that are known to contribute to RCH outcomes while in later years it will be more
outcome focussed. This will require the JRM to focus on communities and blocks with the
worst health outcomes and assess the extent to which RCH funds are being used to reduce
disparities within and between the states.

SCOPE OF THE PRESENT JRM 3

This JRM 3 primarily seeks to review:
1. The extent to which evidence based strategies have been adopted by the states to
reduce MMR, IMR and TFR
2. Implementation progress / bottlenecks and
3. Efficacy of the monitoring system at state and district levels

with emphasis on programme management arrangements and institutional strategies (the
former were envisaged to be in place by April 1, 2005 and the latter substantially
implemented by March, 2006).

Specifically, the scope of the review would include but not be limited to the following:

1. Quality of state and district PIPs
Internal consistency between situation analysis, key issues, strategies, work plan
and costs
Extent to which strategies (maternal, child health, family planning, institutions
including BCC, HMIS, logistics, etc.) are evidence based
Process of preparation and approval of PIPs including mechanisms for
incorporating perspectives of vulnerable groups and approach to consolidation of
district plans into state PIP
Resource allocation criteria e.g. between rural and urban, across districts,
vulnerable groups and between maternal, child health and family planning, BCC,
etc
Monitoring system vis--vis the plan including for tracking access to services by
vulnerable groups, especially SC/ST/adolescents and women

2. Implementation bottlenecks (state and districts)

(focus on activities in the work plan in the areas of e.g. programme management,
institutional mechanisms, maternal & child health, family planning, innovations, financial
management etc)
Reasons for slow pace of implementation:

- 47 -
- Inadequate delegation of powers, cumbersome procedures, financial
bottlenecks, etc.
- Weak programme management structures (state and district health missions
and societies, SPMU/DPMU,
- Inadequate mechanisms for intersectoral convergence / coordination
- Others
Quality of RCH II work carried out including
- Appropriateness of proposed strategies for service delivery, HMIS, BCC,
training etc. in the implementation plan for improved use of RCH services.
- Ability of the key program staff to understand and implement the minimum
service standards recommended for various RCH II technical interventions
including training of staff in emergency obstetric care, newborn care,
expanding contraceptive options and access and in adolescent health
- Ability of the key program staff to understand and implement minimum
physical standards for providing acceptable quality services in strengthening
of 24x7 PHCs and operationalisation of FRUs,).
- Appropriateness of proposed strategies for Public Private Partnerships, and
other innovations in improving delivery of RCH services.
- Quality of program monitoring and financial reporting including audited
statements
Pro poor focus (in e.g. allocation of resources, training and placement of staff in
worse off districts/ blocks, prioritisation of technical interventions / facilities for
upgradation, etc)

3. Monitoring system at state and district levels
Reporting (physical progress and expenditure) including variance analysis
Implementation of new MIES format; disaggregated data to reflect equity
principles, especially improved use of essential RCH services by SC/ST groups.
Community based monitoring and triangulation of data
Extent to which monitoring data is being used by Programme Managers to realign
programmes and re-allocate resources to expand outreach and coverage

4. Progress against priority actions agreed with Programme Divisions during JRM 2:
Reactivate the working group in M&E and start process for contracting agencies to
undertake management reviews and rapid assessments and support states in
triangulation of data on use of essential RCH services.
MOHFW to enhance its stewardship role by making the NHSRC fully functional with
appropriate business plan and start providing technical assistance sought by states
and program divisions.
Accelerate the agreed actions to improve procurement arrangements; (a)
appointment of Procurement Agent/UN agency for supplying essential RCH
commodities; (b) full staffing of EPW; (c) Quality and quantity review; (d)
Implementation of GMP and (e) capacity building of procurement staff.
Initiate regional dissemination of technical guidelines of the program to managers at
state and district levels.

- 48 -
Finalize the IMEP and initiate regional dissemination to all states and districts.
Set up programme management support arrangements for UP and the NE States.
Procurement of essential supplies such as Tab Misoprostol, Inj Magnesium Sulphate,
Inj Oxytocin should also be done in tandem with SBA and other skill-based training,
by the States/Procurement Division, so that the trainees have the facilities to practice
the newly acquired skills in adherence with guidelines.

METHODOLOGY

JRM 3 will adopt the following methodology:
Desk reviews of progress made by the 18 high focus states
Visits to UP, MP and Tripura including a sample of districts
Presentations by programme divisions and all 35 states and UTs on progress since
the last JRM

JRM 3 will need the following inputs:
Consolidated summary reports of progress made by each of the 18 high focus states
during the period April 1, 2005 to September 30, 2006.
State data reporting sheets showing progress until December 31, 2006.
State PIPs for UP, MP and Tripura; sample of district PIPs

REVIEW TEAM
MoHFW 6 participants
State Representatives 2 to 4 participants
Pooling partners 8 participants (3-World Bank; 3-DFID; 2-UNFPA)
Development Partners 6 participants

OUTPUTS:
JRM aide memoire and report card ranking the states based on available RCH
outcome data with specific recommendations for improving quality of state and
district PIPs, overcoming key implementation bottlenecks and strengthening
monitoring. An agreed time bound action plan with MP, UP and Tripura to implement
key recommendations.


- 49 -
TIME LINE

Pre - JRM state visits

Pre-visit Briefing of Teams
Date: Thursday, January 11, 2007
Venue: 249, A, Committee Room, Nirman Bhawan, New Delhi
Time: 3:00 5:00 PM

Visits
States Teams Dates GoI Officers
Madhya
Pradesh
GoI + GTZ + DFID +
UNFPA + one State
Health Secretary
15-19 January,
2007 (Monday to
Friday)
*Dir (MH/Stat), Dir
(RCH Finance),
AC (MH)
Uttar Pradesh GoI + WB + USAID +
UNICEF + one State
Health Secretary
15-19 January,
2007 (Monday to
Friday)
*Dir (Stat), Dir (IFD),
AC (CH)
Tripura GoI + EC + WHO + JICA
+ one State Health
Secretary
15-19 January,
2007 (Monday to
Friday)
Dy. Dir (DC), FMG
representative,
AC (Trg) *
* Team Leader

National Review (Phase I) January 23-25, 2007
Venue: 249, A, Committee Room, Nirman Bhawan, New Delhi

Date Session Time Program Div.
Forenoon 11.00 a.m. to
1.00 p.m.
(i) Programme Management / DC
(ii) Procurement
Lunch 1.00 p.m. to 2.00 p.m.
23
rd
Jan, 2007
Tuesday
Afternoon 2.00 p.m. to
5.30 p.m.
(iii) Financial Management
(iv) Monitoring and Evaluation
(v) IEC
(vi) ARSH
Forenoon 10.30 a.m. to
1.30 p.m.
(vii) Maternal Health
(viii) Child Health
(ix) Family Planning
Lunch 1.30 p.m. to 2.30 p.m.
24
th
Jan, 2007
Wednesday
Afternoon 2.30 p.m. to
5.30 p.m.
(x) Training
(xi) NGO
(xii) North East Division
25th Jan, 2007
Thursday
Forenoon 10:30 a.m. to
1:30 p.m.
Presentations of JRM Field Visits to
Madhya Pradesh
Uttar Pradesh
Tripura

- 50 -


National level Review of States (Phase II) 29
th
January to 5
nd
February 2007
Venue: 249, A, Committee Room, Nirman Bhawan, New Delhi

Date Time States
29
th
January, 2007
Monday
10.00 a.m. to
5.30 p.m.
Bihar, West Bengal, Karnataka, Delhi, Goa
31
st
January, 2007
Wednesday
10.00 a.m. to
5.30 p.m.
Gujarat, Orissa, Rajasthan, Andhra Pradesh, Kerala,
Uttar Pradesh
1
st
February, 2007
Thursday
10.00 a.m. to
5.30 p.m.
Madhya Pradesh, Chhattisgarh, Jammu & Kashmir,
Himachal Pradesh, Punjab, Haryana
2
nd
February, 2007
Friday
10.00 a.m. to
6.00 p.m.
Assam, Arunachal Pradesh, Manipur, Meghalaya,
Mizoram, Nagaland, Sikkim, Tripura
5
th
February, 2007
Monday
10.00 a.m. to
5.30 p.m.
Andaman & Nicobar, Lakshadweep, Puducherry,
Daman & Diu, Dadra & Nagar Haveli, Chandigarh,
Maharashtra, Uttarakhand, Tamil Nadu, Jharkhand




















ANNEX 2

RCH II PROCESS INDICATORS

- 51 -
ANNEX 2
RCH II PROCESS INDICATORS

Sr.
No.
RCH INDICATOR Level of
achievement
Calculation of the indicator by the State& methodology of
data collection in JRM
Task to be performed in JRM
Review
1 % of ANM positions
filled
80% Source of Information: Programme Data/Financial Data on Salary
disbursement
Type: Secondary
Definition:
Number of ANMs in Position on 1
st
Jan 2007 X 100
Total number of ANM positions including
Contractual positions sanctioned
Vacant is defined as regular vacancies against sanctioned plus
those approved for contractual appointments
Analysis of data presented by the State
2 a. % of districts
having full-time
programme manager
for RCH
b. Administrative and
financial powers
delegated
90% Source of Information:
FMIS (Release of salary in the previous month)
Data to be captured through secondary source. The indicator has two
parts to it. The first part can be captured through secondary data while
for the second part, the job functions of programme managers and any
other support documents related to administrative and financial
powers will have to be provided.
Type: Secondary:
This data can be compiled from the finance section through salary
disbursement (district-wise)
Definition:
Number of districts having full-time programme
managers in position as on date X 100
Number of districts in the state
Analyze data; discuss about vacant
positions (if any) and explore if any
steps have been initiated for filling in
vacancies.
Check if RCH Programme Managers
also handle any other responsibilities.
Additionally, many officers may be
handling different responsibilities of RCH
check this too
3 % of sampled state
and district program
managers aware of
their responsibilities
80% Source of Information: Programme Data
Check out whether the state is capturing this information? If no, ask
state to use proxy variable and provide

Proxy:
Number of Program Managers underwent
induction/orientation programme X 100
Number of Program Managers sampled
Depending on the scores, the JRM can
frame their questions

- 52 -
Sr.
No.
RCH INDICATOR Level of
achievement
Calculation of the indicator by the State& methodology of
data collection in JRM
Task to be performed in JRM
Review
4 % of sampled state
and district
programme managers
whose performance
was reviewed during
the past six months
60% Source of Information: Programme Review Minutes
Number of programme reviews done in the last six months

Type: Secondary
Number of programme managers whose
performance was reviewed in the past six months X 100
Number of programme managers sampled
If the state has not conducted any
programme managers review, then they
have to be probed for reasons?
-How have they then been monitoring
their performance? How is the
information consolidated?
-Have they initiated any steps in this
direction? If so, what all steps have been
initiated?
5 % of district not
having at least one
month stock of
a. Measles Vaccine
b. OCP
c. Gloves
<10% Source of Information: Stock Register/MIS

Type: Secondary
This information has to be compiled from stock registers maintained at
district level. Compile district-wise information for last six months by
opening balance, received, distributed and balance (month-wise)
Examine data on logistics and discuss if
any flaws are observed. Find out the
logistics mechanism (indenting,
procurement, disbursement etc) followed
by the state
6 % of districts
reporting quarterly
financial performance
in time
80% Source of Information: FMIS Collect for two quarters
Ask when districts were supposed to report and when reported.

Type: Secondary (reference period July December 2006)

Definition:
Number of districts reporting quarterly financial
statement on time X 100
Total Number of districts
Analyze data by districts and find out
reasons for delay (if any). Examine by
budget heads so that an idea of major
expenditure can be gauged and
subsequently areas of reviews and
questions could be framed for district
visits

- 53 -
Sr.
No.
RCH INDICATOR Level of
achievement
Calculation of the indicator by the State& methodology of
data collection in JRM
Task to be performed in JRM
Review
7 % of district plans
with specific activities
to reach vulnerable
communities
80% Source of Information:
State consolidated summary matrix of interventions by districts (if
available)

Type: Secondary:
State can be asked to look into PIPs and compile district-plan activities
in matrix form if not available.
Definition:
Number of districts with specific vulnerable plans X 100
Total Number of districts
Definition of Vulnerable community: SC, ST, BPL, not
accessible/remote areas planning etc.
Examine census distribution of SC/ST
population and analyze district
vulnerable plans against it. For BPL and
other indicators, find out the rating from
state and undertake the review
8 % of sampled
outreach sessions
where guidelines for
AD syringe use and
safe disposal
followed
80% Source of information:
Routine Immunization records
Type: Secondary
Definition:
Number of sampled outreach sessions where AD syringe
use and safe disposal guidelines are being followed X 100
Number of sampled outreach sessions
AD syringe logistics in terms of supply
and distribution can be verified at district
level and few ANMs can be asked
related questions
9 % of sampled FRUs
following agreed
Infection Prevention
and health care
waste disposal
procedures

80% Source of information:
-Correspondences between state and district and district and FRUs
on IP and waste disposal protocols
-Training related to the above
-IP supplies during the year at district etc.

Type: Secondary
If this activity has been initiated, then check with the state of what all
activities have been done in this regard and whether any sample
check has been undertaken. If yes, then ask the state to provide
information by using the following definition
Definition:
Number of sampled FRUs following agreed IP and
waste disposal protocols X100
Number of sampled FRUs
(MIS doesnt capture this information)

- 54 -
Sr.
No.
RCH INDICATOR Level of
achievement
Calculation of the indicator by the State& methodology of
data collection in JRM
Task to be performed in JRM
Review
10 % of 24 hrs PHCs
conducting minimum
of 10 deliveries per
month
50% Source of information: MIS
Type: Secondary
Definition:
Number of 24 hr PHCs conducting 10 deliveries/ month X 100
Total Number of 24 PHCs in the state
Examine institutional delivery trends of
24hr facility by districts and find out
districts that are performing well and
otherwise. Explore reasons and steps
initiated for increase uptake
11 % of CHCs upgraded
as FRUs offering 24
hr EmOC services
50% Source of information:
MIS/Programme
Type: Secondary
Definition:
Number of CHCs functioning as FRUs X 100
Total number of CHCs proposed during the year

Compile information for 6 months by districts
Check whether progress is according to
work plan or not
12 % of health facilities
offering RTI/STI
services
60% Source of information:
MIS (partial)-Proxy

Type: Secondary
Number of facilities providing RTI/STI services by districts could be
compiled
Number of facilities where lab-tech is posted and available
Number of lab-tech who have undergone RTI/STI training
All facilities where lab-tech has undergone training or having VCTC
can be considered as Numerator

Definition:
Number of health facilities (CHCs and PHCs)
providing RTI/STI services X 100
Number of health facilities (CHCs and PHCs)
RCH Programme is in the process of
developing guidelines and protocols for
RTIs/STIs. They have been following
syndromic treatment guidelines till now.

VCTC has not been a part of RCH in
past and is only being considered now at
PHCs in coordination with NACO.
13 M&E Triangulation
left out















ANNEX 3

INTERMEDIATE INDICATORS

- 55 -


ANNEX 3

INTERMEDIATE INDICATORS

(The starting point for filling this format is the approved PIP for 06-07. Only commitments /
targets in the approved PIP should be filled in. If a commitment has not been made in the
PIP, please ignore the target column. On the other hand, if you have set yourself a target for
an indicator not shown in the list below, bring this into the format. However, achievement
should be filled in wherever relevant, even if you have not set a target. In the remarks
column, provide reasons if achievement is less than pro-rata target for the reporting period).

Name of State: ______________________

Reporting period: October December 2006 (except where specified as cumulative)

S.
No.
Indicator Target as per
PIP (06-07)
Achievement Remarks Source
of data
Infrastructure
1. No. of PHCs upgraded to
provide 24X7 services
1
MIS
No. of health facilities upgraded to FRUs, fulfilling the minimal criteria as per the FRU
guidelines (at least the 3 critical criteria)
a. District Hospitals
1
MIS
b. Sub-Divisional Hospitals
1
MIS
c. CHCs
1
MIS
2.
d. Others (pl. specify)
1
MIS
3. % of functional Sub-Centres
2
MIS
Programme Management
4.
SPMU in place with 100 %
staff
3
MIS
5.
% DPMU staff in place
4
MIS
Training
No. of personnel trained in IMNCI
a. MOs
1

MIS
6.
b. ANMs
1

MIS
c. AWW
1

MIS
d. Others (pl. specify)
1

MIS
No. of personnel trained in SBA
a. MOs
1

MIS
b. ANMs
1

MIS
7.
c. Staff nurse
1

MIS

- 56 -


S.
No.
Indicator Target as per
PIP (06-07)
Achievement Remarks Source
of data
No. of personnel trained in IUD insertion
a. MOs
1

MIS
b. ANMs
1

MIS
8.
c. Staff nurse
1

MIS
No. of MOs trained in
a. Life-saving anaesthesia
skills
1


MIS
b. EMOC
1

MIS
9.
c. NSV
1

MIS
Maternal Health
10.
Proportion of ANC
registrations in first trimester
of pregnancy
5

MIS
11.
% of planned RCH outreach
sessions held in the quarter
6
MIS
Child Health
12.
% of planned Immunization
sessions held in the quarter
6
MIS
Family Planning
13.
% of planned Sterilisation
camps held in the quarter
6

MIS
Adolescent Health
14.
Proportion of ANC
registrations in first trimester
of pregnancy for women <19
years of age
7


MIS
Notes:

1. Please give cumulative figure to date since April 2005 in Target and Achievement columns.
2. Numerator is no. of sub-centres with ANM present and working out of the facility. Denominator is
total no. of sub-centres.
3. SPMU is meant to have four core positions: State Programme Manager, State Data Officer, State
Finance Manager, and State Accounts Manager. Please only report how many of these positions
have been filled (as a percentage). Do not count other consultants for this indicator.
4. Numerator is no. of DPMU positions filled. Denominator is no. of DPMU positions required (no. of
districts X 3 positions per district). The core DPMU positions District Programme Manager, District
Accounts Manager, and District Data Assistant.
5. Numerator is no. of pregnant women who registered for ANC in their first trimester of pregnancy
during the quarter. Denominator is total no. of pregnant women who registered for ANC during the
quarter (reference period October December 2006).
6. The denominator for each of these is no. of sessions/camps planned for the quarter as per the
workplan in the approved state PIP.
7. Numerator is no. of pregnant women <19 years who registered for ANC in their first trimester of
pregnancy (during the reference period). Denominator is total no. of pregnant women <19 years
of age who registered for ANC (during the reference period).


















ANNEX 4

FORMAT FOR FEEDBACK FROM NRHM HIGH
FOCUS STATES ON FUNCTIONING
OF SPMU/ DPMU

- 57 -


ANNEX 4

FORMAT FOR FEEDBACK FROM NRHM HIGH FOCUS STATES ON
FUNCTIONING OF SPMU/ DPMU

The format has the following sections:
A. Staffing status and induction training
B. Working environment
C. Organisational aspects
D. Deliverables: annual
E. Deliverables: quarterly

For the purpose of this JRM, please fill all the sections.

A. STAFFING STATUS AND INDUCTION TRAINING

SPMU In position
Y / N
(Please tick)
Has undergone
induction training
Y / N (Please tick)
Remarks (if any)
State Program
Manager
Y N Y N

State Finance
Manager
Y N Y N

State Accounts
Manger
Y N Y N

State Data
Officer
Y N Y N

Others

Y N Y N



- 58 -



DPMU Positions
sanctioned
(No.)
Positions
filled (No.)
No. of
persons
undergone
induction
training
Remarks
(if any)
District
Program
Manager

District
Accounts
Manager

District Data
Assistant

Others



B. WORKING ENVIRONMENT

SPMU
S
No.
Item/
Equipment
Description Y / N
(Please
tick)
Remarks
(if any)
1 Adequate office
space for
SPMU
Separate table/ chair, storage space
for each staff member Y N

2 Computers Individual PCs in good working
condition, with at least one shared
printer and with internet connection
Y N

3 Telephone One official telephone, with internet
connectivity.
Y N

4 Fax
/photocopier
Access to fax and photocopying
facilities, if available within the office,
or an arrangement with an external
service provider. Should not be a
constraint.
Y N

5 Travel
arrangements
for work related
travel
Through taxis/department
vehicles/public transport. Should not
be a constraint to carrying out their
respective functions
Y N



- 59 -


DPMU

S
No
Equipment Description No. of
districts w/
equipment
Remarks
(if any)
1 Adequate office
space for DPMU
Separate table/ chair, storage
space for each staff member

2 Computers Individual PCs in good working
condition, with at least one
shared printer and with internet
connection

3 Telephone One official telephone, with
internet connectivity.

4 Fax /photocopier Access to fax and photocopying
facilities, if available within the
office, or an arrangement with an
external service provider. Should
not be a constraint.

5 Travel
arrangements for
work related
travel
Through taxis/department
vehicles/public transport. Should
not be a constraint to carrying out
their respective functions


C. ORGANISATIONAL ASPECTS

1. Is there an operating Job description with indicators of performance?

SPMU Y / N
(Please tick)
Remarks
(if any)
State Program
Manager
Y N
State Finance
Manager
Y N
State Accounts
Manger
Y N
State Data
Officer
Y N
Others




- 60 -



DPMU Y / N
(Please tick)
Remarks
(if any)
District Program
Manager
Y N
District Accounts
Manager
Y N
District Data
Assistant
Y N
Others



2. Reporting structure

Items Y / N
(Please tick)
Remarks
(if any)
1. SPM reports to Mission Director/
State Programme Officer for RCH
Y N
2. SFM, SAM and SDO report to
SPM
Y N
3. DPM reports to CMHO/CMO Y N
4. DAM and DDA report to DPM Y N
5. DPMU staff functionally report to
their SPMU counterparts (DPM to
SPM, DAM to SFM / SAM, DDA
to SDO)
Y N


3. HRD systems

Items Y / N (Please tick)
Remarks
(if any)
1. Is there a performance appraisal
system for SPMU and DPMU
Y N
2. Is there a system for training of
SPMU/ DPMU staff including
training needs assessment and
post training evaluations
Y N
3. Are administrative procedures
including working hours, leave,
official travel etc. laid down
Y N
4. Is there a external human
resources management agency or
a dedicated HRM unit/ person in
Y N

- 61 -


Items Y / N (Please tick)
Remarks
(if any)
the department responsible for
SPMU/DPMU staff
5. Is there a compensation review
system for SPMU and DPMU staff
Y N
6. Is there a HRD Manual
documenting the above in place
Y N

D. DELIVERABLES (ANNUAL)

SPMU
Function Indicator/ Means of
verification
Please
provide
specific
information
Remarks
(if any)
1. State specific planning
and monitoring manual
prepared, updated and
disseminated to districts
Planning manual,
records of
dissemination
workshops
Y N

2. DHAPs received and
appraised before the
beginning of financial year
Appraisal reports
% of districts

3. Develop/update and
disseminate accounting
manual
Accounting
manual Y N

4. Staff trained in districts in
using the accounting
manual
Records of
training
programmes/
workshops
% of district
DAMs trained

5. Funds released to
districts/ spending centres
as per the work plan/
budget of state PIP/DHAP
Funds flow
statement/ Field
visit to a sample
group of districts
% of funds
disbursed

6. UCs collected from
districts and submitted
within agreed time frame
along with a financial
analysis report
Financial
monitoring report
% of districts

7. Auditing firm for
conducting audits of state/
districts audits appointed
Appointment
letter issued to
auditing firm(s)
Y N

8. Annual audit of SHS
accounts is completed
within the stipulated time
frame
Audit report
prepared and
submitted within
the stipulated
timeframe
Y N



- 62 -


DPMU

Function Indicator/ Means
of verification
Y / N

Remarks
(if any)
1. Ensure preparation/
approval of DHAP before
the beginning of financial
year
DHAP prepared

If Yes (Y)
% of
districts =

2. Auditing of DHS accounts
completed within
stipulated time
Audit report
received at
SHS/SPMU
If Yes (Y)
% of
districts =


D. DELIVERABLES (QUARTERLY)
SPMU
Function Indicator/ Means of
verification
Y / N
(Please tick)
Remarks
(if any)
1. Ensure submission of quarterly
physical monitoring reports in
accordance with planning
manual/ against PIP workplan
Physical
monitoring report
received on time
Y N

2. Ensure submission of quarterly
monitoring reports in accordance
with financial manual/FMR
Financial
monitoring report
received on time
Y N

3. Regular (at least once a quarter)
periodic meetings of DPMUs
convened for information sharing/
sorting out operational issues
Records of
meetings
Y N

4. Number of process improvement
proposals prepared at state level,
piloted
Number of
proposals piloted.

No. of
proposals

5. SHM/ SHS meetings scheduled
as envisaged in MOU/ SHS bye
laws
Records of
meetings. Y N


DPMU
Function Indicator/ Means
of verification
Y / N

Remarks
(if any)
1. Ensure submission of quarterly/
monthly monitoring reports in
accordance with planning/financial
manual
Timely
submission of
monitoring
reports to SPMU
If Yes (Y)
% of
districts =

2. Proposals for process
improvement prepared and
submitted to SPMU/DHS for
appraisal/approval (each district to
send at least one proposal)
Appraisal
reports of the
proposals
If Yes (Y)
% of
districts =




















ANNEX 5

M&E CAPACITY ASSESSMENT CHECKLIST


- 63 -


ANNEX 5

M&E CAPACITY ASSESSMENT CHECKLIST

S. No. ITEM NO.
A GENERAL

A.1 Does the State Govt have a computerised Health
Management Information System (HMIS) in position for
the NRHM/RCH Programme
Yes/No

If Yes in A.1, please give the following information for
the IT infrastructure for the NRHM Programmes
Remarks, if any
(a) Are the Computers linked to a Local Area Network
within the Health & FW Directorate
Yes/No
(b) Indicate the software platform on which the HMIS is
structured on (MS Excel, MS ACCESS, SQL,
ORACLE, SAS etc)

(c) Is there Internet connectivity on the LAN Yes/No
A.2
(d) Does the HMIS facilitate e-mode transfer of
information vide area network.
Yes/No
A.3
If No in A.1, please indicate whether there are any
plans for establishing a competent HMIS
Yes/No
A.4
Number of Districts having PC, Printer and Internet
connectivity (Count those that have all three)

B FINANCIAL Current Year
(Rs in Lakhs)
Previous Year
(Rs in Lakhs)
B.1 Please indicate the amount of funds earmarked for
Monitoring and Evaluation Activities in the State
PIP

Please indicate the amount of funds earmarked for the
following Monitoring and Evaluation Activities

(a) Establishing HMIS at district and sub-district levels
(b) Acquisition /upgradation of hardware
(c) Acquisition/ development of Software
(d) Training of Manpower on IT Skills
(e) Training of manpower at all levels
(f) Salary and Allowances of contractual staff (MIS,
Statistician, data entry operator etc)

(g) AMC of hardware/software
B.2
(h) Others specify
C HUMAN RESOURCES
C.1
Has state created M & E Cell at the State level Yes/No

- 64 -


S. No. ITEM NO.
C.2 Has a Nodal Officer been identified for M & E activities
at State Level?
Yes/No
C.3 Number of Districts where a Nodal Officer has been
identified for M & E activities?

C.4 Total Number of Districts having Statistical Manpower/
Data Manager/ Entry operator?

C.5 Is there any provision of Statistical Manpower (Data
Entry operator / Statistician) in M&E cell of DPMU?
Yes/No
D INFRASTRUCTURE & TRAINING

D.1 Infrastructure availability No. of
Computers
No. of computer-
trained personnel
(a) At State HQ (SPMU)

(b) At District HQ (DPMU)

(c) At CHC

(d) At PHC

D.2 Is there any proposal for training of manpower at all
levels in the data reporting machinery? If so please
give the details in a separate sheet.
Yes/No
E
OTHERS
E.1 Has State undertaken household and facility surveys
for creating the frame/base for health & family welfare
related indicators? If yes, please indicate the year of
the Survey.

E.2 Has detailed activities /work plan of M&E activities
given in the State PIP
Yes/No
Does the State Govt have a Web site for the Health
Sector? If so give please give the web-site address of:

(a) Department of Health & FW
(b) NRHM, if separate
(c) State Health Resource Centre
(d) State Institute of Health & FW
E.3
(e) Any other related Institution (specify)

Remarks, if any


















ANNEX 6

CHECKLISTS

- 65 -


ANNEX 6

CHECKLIST # A

DISCUSSION WITH STATE/DISTRICT LEVEL PROGRAMME MANAGERS

(This checklist is to be used for discussions with State NRHM Director/ state RCH nodal
officer, District CMHO/ District RCH nodal officer, SPMU/ DPMU staff and other key
personnel. The purpose of this checklist is to ascertain:
The extent to which state and district PIPs are internally consistent and incorporate
evidence based strategies (a copy of the state PIP is attached; PIPs for districts to be
visited will need to be collected from the state)
Implementation bottlenecks
Existing monitoring system

The emphasis is on identifying a few key issues, developing detailed recommendations with
emphasis on how to implement and agreeing an action plan for implementation).

State and district PIPs

1. PIP preparation at state and district levels
a. Nodal persons in place at state and district levels; job clarity; role of SPMU/DPMU
b. Consultations at state/ district/block level
c. Facility mapping
d. HR mapping and rationalisation
e. Training needs assessment
f. Identification and mapping of vulnerable groups (SC/ST/BPL/nomadic population)
and worse off districts
g. How are rights and gender mainstreaming incorporated in PIPs?
h. Other means of information for situation analysis and planning

How are strategies identified and prioritised any evidence base? Are these linked to
the situation analysis? Do worse off districts/ blocks get priority in training and placement
of staff and facilities for upgradation?
i. Depth of planning for PPP/ innovations
j. How are strategies/ activities costed?
k. How are resources allocated across districts, between rural and urban areas? And
across e.g. MH/CH/FP, different non-technical components?
l. To what extent do districts get untied funds or is 100% of the amount linked to state
schemes?
m. Has performance based funding to districts been considered?
n. How do district plans feed into the state plan? Are state responsibilities clearly
identified and time lines linked with district plans?
o. How are district/ state plans approved?


- 66 -


Implementation bottlenecks (state and districts)

(Based on State and district PIPs identify a sample of strategies/ activities where progress is
slow. A good reference point might be the summary state report- attached separately;
selected activities could be technical e.g. strengthening of 24x7 PHCs, operationalisation of
FRUs, SBA training, outreach sessions for service delivery, IMNCI, child immunizations,
promotion of NSV and spacing methods, ARSH services, health care waste management
practices at facility levels, etc. or programme management/ institutional strategies. Probe in
detail in order to identify root cause of delay; discuss options for way forward)

2. Is the pace of implementation according to plan? If not, reasons for delay
a. Was it an ambitious plan to begin with?
b. Is it a problem with the sequencing of activities?
c. Is there adequate delegation of powers both administrative and financial?
d. Is RCH II a priority for the district collectors?
e. Are the procedures cumbersome Goa Conference suggested mechanisms for
easing the procedures at the district levels. Are those being followed?
f. Any financial bottlenecks time taken for funds to be received from the centre, time
taken for funds to be released from state to districts and from districts to blocks, etc.

3. Are programme management structures in place and are we getting results?

(These were envisaged to be largely in place by April 2005 and hence should be separately
addressed. If substantial work still remains in setting them up/ strengthening them, how is it
impacting programme implementation?)
a. Functioning of integrated state/ district societies
(Collect minutes of meetings. Is RCH II getting sufficient attention?)
b. Reasons for contractual vacancies in SPMU/ DPMU staff/ Consultants.
(Need to probe time taken to initiate recruitment process, interviews held, and status
on joining, dropouts on joining and turn over rates)
c. Reasons for not completing induction training for all contractual staff
(If more than 20 percent contractual staff has not undergone training: what are the
plans to complete training, in-state training resources, availability of training material,
etc)
d. Role clarity and role conflicts between contractual PM staff and regular programme
managers.
(Matching job descriptions, reporting requirements, discussions on the possibility of
conflicts and conflict resolution mechanisms. Has the HR function for contractual staff
been put in place e.g. through a HR cell or outsourcing? Is there a HRD manual in
place?)
e. Perceived contributions of SPMU & DPMU? what is the value add ? has programme
management become more effective/ evidence based ? or do the SPMU/ DPMU staff
spend time essentially on leg work / carrying out routine admin tasks ?

- 67 -



4. Are Institutional strategies in place and is there any ground level impact?

(These were envisaged to have been substantially in place by April 2006 i.e. Institutional
Mobilisation Phase, and hence separately addressed. Again select strategies from the PIP,
examine pace of implementation and results on the ground).

Selected strategies could be:
a. Cadre review/ work force management
b. HMIS: also see Annex 5
c. Training: Status on skill-upgradation of service staff, training infrastructure,
availability of trainers/ course material; quality of training.
d. BCC/IEC Activities: Is there evidence of shift from IEC to BCC? Is there a formal
BCC strategy in place? How is the strategy linked to service delivery? What is the
relative role of state/ district/ block and IPC?
e. PPP/ Innovations/ NGO

Monitoring system at state and district levels (also see M&E Checklist F)

5. Is there any attempt to monitor progress against the plan in the State/ District PIP, both
in terms of physical targets and expenditure? Is a variance analysis carried out?
6. Who is responsible for this function? What is the relative role of state demographer/
district statistical officer and SPMU/DPMU staff?
7. What reports are provided to CMHO/ NRHM Director/ nodal officer? How are the reports
used to make mid course corrections? (illustrations would be useful)
8. PNDT Monitoring
- Are all clinics registered? How many registered in last quarter? How many still not
registered?
- Are cases getting reported? How many in the last quarter? What action was
taken?
- Any surprise checks done in the last quarter? (see reports)
- Are any reports sent to GOI? (check any recent reports)
- What PNDT training/awareness activities have been conducted this year?
9. Quality Assurance Pilot (only for UP visit)
- Has the state signed the Terms of Reference regarding the role of the State, GOI,
and the Development Partners?
- What are the plans for/ status of setting up of the Quality Assurance units at state
and district levels?
- Are any funds earmarked for Quality Assurance?
- Any other activities?



- 68 -


CHECKLIST # B

FGD Guide:

Focus Group Discussion with 8-10 married women in Reproductive Age group
(women from VGs).

Note: The purpose of this checklist is to look at the quality of services on the ground
peoples perceptions, awareness about services available (effectiveness of IEC),
etc.

Key Areas:

1. Knowledge about availability of health services in general/ reproductive health
services in particular in the village and nearby villages

2. Knowledge about JSY

3. First Port of call in problems during pregnancy & delivery and for medical care

4. Action in the event of Obstetric complications such as PPH.

5. Availability of common RH commodities such as condoms/ORS/IFA available in
villages.

6. Regularity of sessions and range of services in outreach villages.

7. Opinions about availability of ANM

8. Awareness about entitlements from health system

9. Attitude of the providers in public system

10. Reasons for accessing private sector for medical care services

11. Recall of any health information/communication campaigns conducted in the village
recently, key messages (check on Breast feeding, HIV/AIDS or immunization)

12. Participation in SHG meetings and discussions on health issues.


- 69 -


CHECKLIST # C

Facility Observation Checklist

Note: The purpose of this checklist is to look at the range and quality of services
available at facilities.
District: _________________________
Name of Institution: _________________________
Date of visit: _________________________
1. Service provision
Routine Delivery Services (24 hours)
Manage common obstetric complications
C-section
New born care
Female sterilisation services
NSV Services
MTP

2. Staff availability
Ob/Gyn Specialist/Trained M.O
Anaesthesiologist/trained M.O
Staff Nurses/ANMs at least (4)
Lab Technicians

3. Equipments and Supplies

NSV equipments kit
Gluteradelyde Solution
RPR Test Kits
Injection Magnesium Sulphate
Capsule Doxycycline
Functioning BP instrument
Measles vaccine

4. Facility Infrastructure

Infrastructure Needs Assessment Done
Blood Storage Facility
Plans for hospital bio-waste disposal
Visual Privacy in labour room
Visual privacy in OPD
Back-up power facility

5. Referral Services
Availability of an ambulance or a outsourced vehicle for referral

6. Client Convenience
Covered waiting area
Separate functional and clean toilets for Male/Female
Signage to guide clients (information to client on
user charges, timings)

7. Record Review
Average no. of monthly deliveries in the facility for last quarter

Yes/ No
Yes/ No
Yes/ No
Yes/ No
Regular/ Periodic
Regular/ Periodic
Regular/ Periodic


Yes/ No
Yes/ No
Yes/ No
Yes/ No


Yes/ No
Yes/ No
Yes/ No
Yes/ No
Yes/ No
Yes/ No
Yes/ No


Yes/ No
Yes/ No
Yes/ No
Yes/ No
Yes/ No





Yes/ No
Yes/ No

Yes/ No



_________

- 70 -


CHECKLIST # D

MONITORING AND EVALUATION

(to be used in conjunction with Annex 5)

1. Do you have a separate plan for M&E? How do you intend to capture the new
components of RCH II and address specific issues of vulnerability?

a. Have you modified the registers and reports to cater to the new needs of RCH
II? Have you been able to capture information provided to vulnerable
population? Explore and find out how they have been managing?

2. What are the registers and reports presently being maintained? What registers and
reports are being sent to GOI?

3. What M&E activities have been initiated? List the activities and the extent to which it
has been adhered? If no, what are the reasons? List all of them? Have you evolved a
system for coverage of private facilities (PPP)? If so, provide us the details of the
mechanism.

4. How have you been tracking performance? Explain? What initiatives have you taken
in regard to:

a. Coverage
b. Quality of data- adequacy
c. Timeliness
d. Supervisory visits
e. System of giving feedback and follow-up

(Check documents related to itinerary of supervisory visits, actual visit, feedback
and follow-up)





















ANNEX 7

INDICATIVE FORMAT FOR PROGRESS
AGAINST APPROVED RCH II WORK PLAN
FOR 06-07

- 71 -


ANNEX 7

INDICATIVE FORMAT FOR PROGRESS AGAINST APPROVED RCH II WORK PLAN FOR 06-07
REPORTING PERIOD: September December 2006


States are requested to provide feedback on:

(1) Progress vis--vis commitments made in their respective PIPs/ work plans in terms of:
- Intermediate and process indicators
- Physical progress
- Utilisation of funds
- Variance and its analysis

(2) Status of implementation of key recommendations of the Second JRM

States should also spell out:
- Any implementation bottlenecks
- Action taken / proposed remedial measures
- Need for technical assistance, if required.










- 72 -


States should use the format provided below. This should form the basis for the states JRM presentation at Delhi. A copy of the
filled in format should be provided to the JRM team.

Physical Finance
Activity Physical target for
the year (if
applicable)
Achievement %
achievement
Budgeted
amount
(Rs lakhs)
Utilization
(Rs lakhs)
% utilization
1.1 Programme management
(State & District Levels)

Activity 1.1.1
Activity 1.1.2
Activity 1.1.3, etc

1.2 Infrastructure
Activity 1.2.1
Activity 1.2.2
Activity 1.2.3, etc

1.3 Logistics / Procurement
Activity 1.3.1
Activity 1.3.2
Activity 1.3.3, etc


Sub total


- 73 -


Training

Physical Finance
Activity Physical target for
the year (if
applicable)
Achievement %
achievement
Budgeted
amount
(Rs lakhs)
Utilization
(Rs lakhs)
% utilization
Activity 2.1
Activity 2.2
Activity 2.3, etc


Sub total

Monitoring and Evaluation

Physical Finance
Activity Physical target for
the year (if
applicable)
Achievement %
achievement
Budgeted
amount
(Rs lakhs)
Utilization
(Rs lakhs)
% utilization
Activity 3.1
Activity 3.2
Activity 3.3, etc


Sub total



- 74 -


Family Planning

Physical Finance
Activity Physical target for
the year (if
applicable)
Achievement %
achievement
Budgeted
amount
(Rs lakhs)
Utilization
(Rs lakhs)
% utilization
Activity 4.1
Activity 4.2
Activity 4.3, etc


Sub total

Maternal Health

Physical Finance
Activity Physical target for
the year (if
applicable)
Achievement %
achievement
Budgeted
amount
(Rs lakhs)
Utilization
(Rs lakhs)
% utilization
Activity 5.1
Activity 5.2
Activity 5.3, etc


Sub total


- 75 -


Child health


Physical Finance
Activity Physical target for
the year (if
applicable)
Achievement %
achievement
Budgeted
amount
(Rs lakhs)
Utilization
(Rs lakhs)
% utilization
Activity 6.1
Activity 6.2
Activity 6.3, etc


Sub total

Adolescent Health

Physical Finance
Activity Physical target for
the year (if
applicable)
Achievement %
achievement
Budgeted
amount
(Rs lakhs)
Utilization
(Rs lakhs)
% utilization
Activity 7.1
Activity 7.2
Activity 7.3, etc


Sub total


- 76 -


Urban Health

Physical Finance
Activity Physical target for
the year (if
applicable)
Achievement %
achievement
Budgeted
amount
(Rs lakhs)
Utilization
(Rs lakhs)
% utilization
Activity 8.1
Activity 8.2
Activity 8.3, etc


Sub total

Tribal Health

Physical Finance
Activity Physical target for
the year (if
applicable)
Achievement %
achievement
Budgeted
amount
(Rs lakhs)
Utilization
(Rs lakhs)
% utilization
Activity 9.1
Activity 9.2
Activity 9.3, etc


Sub total
























ANNEX 8

METHODOLOGY FOR RANKING OF STATES

- 77 -


ANNEX 8

METHODOLOGY FOR RANKING OF STATES

BACKGROUND
The purpose of ranking of performance of states on RCH II is to bring in an element of
competition amongst states thereby providing the motivation to improve their performance;
enable states to focus on key issues/ indicators; and to provide a basis for award of
incentives/bonus.
Progress against the RCH II process indicators is perhaps a fair basis for judging
performance. It is recognised that the necessary data may not be as reliable as desired, but
could provide an opportunity to look at trends. Further, the various surveys underway and on
going strengthening of HMIS would lead to availability of better data in the future. For the
purpose of this exercise, indicators will be selected largely on the basis of data availability
and equal weightage will be given to each indicator.

INDICATORS
The indicators to be used in this exercise will be selected largely from amongst the RCH
process indicators specified in the NPIP. The cut off percentage for the process indicators
are as per the PIP. Each indicator will be given equal weight. A score of 0 will also be given
where information on the particular indicator is not made available.

The following indicators are proposed for this ranking:
1. At least 80% ANMs in place
2. At least 90% of districts having full-time programme manager for RCH with financial and
administrative powers delegated
3. Less than 10% of districts not having at least one month stocks of (a) measles vaccine,
(b) OCPs, and (c) gloves.
4. At least 50% of 24 hr PHCs conducting minimum 10 deliveries per month
5. At least 50% of upgraded FRUs offering 24 hour emergency obstetric care services
6. At least 75% DPMU positions filled and trained
7. At least 50% of funds utilized (out of release)

Other indicators may be added.

RANKING AND GRADE
The states will be ranked based on the overall score. A further grading will be done based on
the overall score.
















ANNEX - B

STATE WISE DATA ON MMR, IMR AND TFR

- 78 -


ANNEX B
STATE WISE DATA ON MMR, IMR AND TFR
Sl. No. State
MMR IMR TFR

SRS
2001-03
SRS
1999-01
SRS
2000
SRS
2005
SRS
2000
SRS
2004
NFHS 2
1998-99
NFHS 3
2005-06
India 301 327 68 58 3.2 2.9 2.9 2.7
A. EAG States
1 Bihar 371 400 62 61 4.5 4.3 3.7 4
2 Chhattisgarh 379 407 79 63 -- 3.3 2.8 2.6
3 Jharkhand 371 400 70 50 -- 3.5 2.8 3.3
4 Madhya Pradesh 379 407 87 76 4.0 3.7 3.4 3.1
5 Orissa 358 424 95 75 2.8 2.7 2.5 2.4
6 Rajasthan 445 501 79 68 4.1 3.7 3.8 3.2
7 Uttar Pradesh 517 539 83 73 4.7 4.4 4.1 3.8
8 Uttarakhand 517 539 50 42 -- -- 2.6 2.6
B. Other States
9 Andhra Pradesh 195 220 65 57 2.3 2.1 2.3 1.8
10 Gujarat 172 202 62 54 2.9 2.8 2.7 2.4
11 Goa -- -- 23 16 -- -- 1.8 1.8
12 Haryana 162 176 67 60 3.2 3.0 2.9 2.7
13
Himachal
Pradesh -- -- 60 49 -- 2.1 2.1 1.9
14 J & K -- -- 50 50 -- 2.4 2.7 2.4
15 Karnataka 228 266 57 50 2.4 2.3 2.1 2.1
16 Kerala 110 149 14 14 1.9 1.7 2 1.9
17 Maharashtra 149 169 48 36 2.5 2.2 2.5 2.1
18 Punjab 178 177 52 44 2.4 2.2 2.2 2
19 Tamil Nadu 134 167 51 37 2.1 1.8 2.2 1.8
20 West Bengal 194 218 51 38 2.4 2.2 2.3 2.3
C. (Union Territories)
21
Andaman &
Nicobar -- -- 23 27 -- --
22 Chandigarh -- -- 28 19 -- --
23
Dadra & Nagar
Haveli -- -- 58 42 -- --
24 Daman & Diu -- -- 48 28 -- --
25 Delhi -- -- 32 35 -- 2.1 2.4 2.1
26 Lakshadweep -- -- 27 22 -- --
27 Puducherry -- -- 23 28 -- --
D. (North Eastern States)
28
Arunachal
Pradesh -- -- 44 37 2.5 3
29 Assam 490 398 75 68 3.1 2.9 2.3 2.4
30 Manipur -- -- 23 13 -- -- 3 2.8
31 Meghalaya -- -- 58 49 -- -- 4.6 3.8
32 Mizoram -- -- 21 20 -- -- 2.9 2.9
33 Nagaland -- -- -- 18 -- -- 3.8 3.7
34 Sikkim -- -- 49 30 -- -- 2.8 2
35 Tripura -- -- 41 31 -- -- 1.9 2.2





















ANNEX - C

PERFORMANCE OF STATES AGAINST
RCH II GOALS

- 79 -


ANNEX C
PERFORMANCE OF STATES AGAINST RCH II GOALS

State IMR* MMR** TFR***
Tenth Plan Goal ('07)
= <45/1000
RCH II Goal ('10)=
<30/1000
Tenth Plan Goal ('07)
= 200/100000
RCH II Goal ('10)=
100/100000
Tenth Plan Goal ('07)
= 2.3
RCH II Goal ('10)= 2.1
10th Plan Nat goal 10th Plan Nat goal 10th Plan Nat goal
A EAG States
1 Bihar
2 Chhattisgarh
3 Jharkhand
4 Madhya Pradesh
5 Orissa
6 Rajasthan
7 Uttar Pradesh
8 Uttarakhand
B Other HF states
9 Himachal Pradesh NA NA
10 J & K NA NA
C North East States
11 Arunachal Pradesh NA NA
12 Assam
13 Manipur NA NA
14 Meghalaya NA NA
15 Mizoram NA NA
16 Nagaland NA NA
17 Sikkim NA NA # #
18 Tripura NA NA
D Other States
19 Andhra Pradesh
20 Gujarat
21 Goa NA NA # #
22 Haryana
23 Karnataka
24 Kerala
25 Maharashtra
26 Punjab
27 Tamil Nadu
28 West Bengal
Source of data:
* SRS October 2006 (data for 2005).
** SRS 2001-03, *** SRS 2000
# TFR data for NFHS 3 2005-06;
Goal achieved, NA: Data not available
















ANNEX - D

IMPLEMENTATION STATUS OF PRIORITY
ACTIONS AGREED TO IN SECOND JRM

- 80 -


ANNEX - D

IMPLEMENTATION STATUS OF PRIORITY ACTIONS AGREED TO IN SECOND JRM


Issue Actions
Responsible
body
Time
frame
Action Taken / Current
Status
Series of discussions with
states to ensure
adequate understanding
of the roles and
responsibilities of the
program management
structures and their
relationship and bonding
with the department of
health at the state and
districts.
December
31, 2006
For six high focus states,
draft HRD manual has been
prepared in consultation with
the States.
Confirmation of adoption of
the HRD manual by the
states is awaited.
NERRC has prepared a draft
HRD manual for NE States
and is presently in process
of consultation with them.
HRD strategy review for
state and district program
management units in HP,
J&K and Assam.
DC Division
December
31, 2006
Proposed to be undertaken
in February March 2007.
They have just started
recruitment
Governance/
Programme
Management
A comprehensive
program performance
reporting system vis--vis
the approved State PIPs,
which links outcomes
with strategies, activities
and expenditure from all
sources including state
contribution.
DC Division/
M&E Division
April 2007 To inculcate structured and
standardised physical and
financial monitoring linking
them with the approved PIP
strategies, a draft Operating
Manual in consultation with
M&E Division and FMG has
been prepared and
circulated to all the
programme divisions for
their comments.
Comments are awaited.
Maternal
Health
Ensure provision of a
group of 3-4 technical
consultants to Maternal
Health division to provide
on-site support to the
NRHM focus states in
developing a training
strategy and plans and
ensure availability of
training material, trainers
and examiners,
especially for
anaesthesia training.
They would also provide
support states in
preparing plans for
monitoring training quality
and post training follow
ups for highly skilled
clinical trainings
NHSRC/MH
Division
January
2007
Bio-data for Technical
consultant with a Community
Medicine background have
been short-listed and
forwarded to NHSRC for
conducting interview.
For implementation and
monitoring highly skilled
clinical trainings like
Anaesthesia, EmOC and
SBA training material and
trainers have been made
available in the states. For
monitoring of training quality,
it is in build in the training
guideline. Besides this, a
special cell for Anaesthesia
at AIIMS and for SBA and
EmOC at MH Division is
being created and likely to
be in place by March 2007.
the focus of the cell shall be
on states with poor maternal
health indicators.

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Issue Actions
Responsible
body
Time
frame
Action Taken / Current
Status
National protocols for
management of
RTIs/STIs along with
training guidelines and
material will be finalized
and shared with states
through workshops and
state visits.
MH Division January
2007
National Guidelines on
prevention, management
and control of RTI and STI
have been approved as a
joint document of MH
Division and NACO. This is
also the first example of
preparing guidelines under
inter-sectoral convergence.
A draft operational manual
based on the national
guidelines has also been
prepared and will be
circulated to the members of
2
nd
JRM for their comments,
which will then be finalized &
pilot tested in collaboration
with NIRRH.
Initiate at least 6 regional
workshops to
disseminate technical
guidelines on safe
motherhood and RTI/STI
management to states
with a special focus on
the erstwhile EAG states,
followed up by state visits
of the team of experts
from the MH Division to
ensure accurate
understanding of the
technical guidelines for
FRUs, 24/7 PHCs by the
managers and all service
providers.
States should also
organize similar
workshops for districts.
MH Division





States
December
2006




March
2007
Technical Guidelines have
been disseminated to the
states a number of times
during the Regional
workshops held in the year
2005 and 2006 and also
during RCH II and NRHM
Review of the states.
However, for giving district
specific focus for
dissemination of the
guidelines six regional
workshops have been
planned to be undertaken
from the month of February
to April 2007 as these
workshops could not be held
in December. These will also
not be held again from mid
February to March 2007 due
to the parliament session.
The regional workshops will
be held for the sate level
program managers and a
few program managers form
districts with poor maternal
health indicators shall also
be invited.


NRHM focus states to
prepare IEC plans to
create increased
awareness about the
JSY, especially among
members of local bodies
and community-based
organizations.
NRHM focus
States
December
2006


- 82 -


Issue Actions
Responsible
body
Time
frame
Action Taken / Current
Status
Advise all NRHM focus
states to prepare plans
for refresher training in
SBA for freshly passed
ANMs in government
sector and inclusion of
contents of SBA in pre-
service training of ANMs
and SNs in consultation
with Advisor (Nursing)
and Training Division.
MH Division,
Training
Division,
Advisor
(Nursing)
March
2007
For ANMs and staff nurses
working in the government
sector, training of SBA has
been launched in all the
states.


Evolve strategy to
increase training
institutions for IMNCI at
national and regional
levels including greater
involvement of institutions
from NGO and private
sector.
Child Health
Division
March
2007
Dialogue initiated with IAP,
NNF, IMA.

CARE has agreed to
participate in IMNCI
implementation as well as in
newborn care
implementation
Finalize guidelines for
Home Based New Born
Care and disseminate to
the states.
December
2006
Child Health
Finalize policies on
Micronutrients and
extended authorizations
for use of Gentamycin
and Co-trimoxazole
Child Health
Division
December
2006
Policies for HBNCC,
Vitamin A, IFA, Zn
in place
Finalize a strategy and
plan for enhancing
access to spacing
methods.
December
2006
Alternative training strategy
for IUD in place
Finalize Standard
Operating Procedures for
organizing FP camps
incorporating appropriate
protocols for Quality
Assurance.
December
2006
Being taken up under WHO
biennium funds (0708)- to
complete by June 07
Initiate regional seminars
in NRHM focus states to
disseminate Quality
Assurance guidelines and
sterilizations standards,
and contraceptive
updates to the States
program managers and
service providers,
including nurses.
RSS Division

January
2007
6 two-day workshops
planned in 2007. Two
workshops completed in Feb
March 07. Third to held
on March 15-16 07 at
Nagpur. To be completed
by June 07.
4 contraceptive updates to
be state programme
managers from 20 Non EAG
states given in Nov- Dec06.
Family
Planning
Pilots for PPP in FP
service provision
including injectable
contraceptives are
established.
RSS Division

December
2006
Social marketing in IUD as a
pilot in 3 states in place.
This is being administered
by SSM Division.

- 83 -


Issue Actions
Responsible
body
Time
frame
Action Taken / Current
Status
Assess the infrastructure
and HR needs of
SIHFWs, CTIs, and
RRCs.
Training
Division
January
31, 2007
Letter and reminder has
been sent to CTIs / SIHFWs
and RRCs by Training
Division.
CTIs / SIHFWs have
responded indicating their
needs for infrastructure
strengthening, filling up of
vacant faculty posts and
additional staff requirements.
All States to review their
CTPs and PIPs to ensure
rationalized trainings and
connect them to service
provision
States June 2007 Letter has been sent to
States to provide
information, regarding
available functional / to be
made functional health
facilities and the trained
manpower required for
providing effective services.
NRHM envisages integrating
all training for each category
for all programmes facility
wise.
Training
A section on supportive
supervision to be
incorporated into all
training modules and
guidelines for skills post-
training skill assessment
finalized.
Training
Division/
NIHFW
January
31, 2007
Supportive supervision is
already incorporated in all
the existing training modules
developed by MOHFW/
NIHFW.
Supervisory role of LHVs is
emphasized during the
hands on skill upgradation
training by providing 1 wk
additional training,
specifically on supervision.
Guidelines for immediate
post training proficiency
certificate norms for IST,
SST, SBA & Immunisation
Strengthening have already
been developed by NIHFW
and are being used.
Document and
disseminate best
practices on PPP.
IEC / with
program
divisions
January
31, 2008

Facilitate availability of
contractual technical
assistance to States, and
also provide support for
M&E.
NHSRC/
SHSRC
January
2007

Formats for evaluating
on-going innovation to be
ready for use.
M&E Division June 2007
Innovations in
service
delivery
Assessment report on the
progress of the NGO
scheme to be provided.
NGO Division By next
JRM


- 84 -


Issue Actions
Responsible
body
Time
frame
Action Taken / Current
Status
BCC unit at the national
level to be fully staffed
with clear roles,
responsibilities and
deliverables for the staff.
IEC Division January
31, 2007

The BCC units at the
state and district levels
for erstwhile EAG and NE
states, J&K and HP will
be fully staffed (including
outsourcing options)
respectively with clear
roles, responsibilities and
deliverables for the staff.
Erstwhile
EAG and NE
states, J&K
and HP
March 31,
2007 and
May 31,
2007

Mechanism to support
states in development of
a comprehensive and
integrated BCC strategy.
January
31, 2007

Organise TA for capacity
building of state
counterparts to plan,
implement and monitor
BCC activities.
December
2006

Demand
Creation
Strengthen the
ASHA/AWW/ANM
training with interpersonal
communication skills to
adequately address
patient concerns and
empower patient
decision-making.
IEC Division
June 2007
Reactivate the M&E
Working Group
M&E Division October
31, 2006,

Develop a pilot proposal
for community based
monitoring and prepare a
short list of appropriate
institutions for its
implementation.

TA to be provided.
January
31, 2007




November
2006.

TA to be provided for
developing a framework
for triangulation.
November
2006

Monitoring
and
Evaluation
Organize series of state
level workshops to train
state and district level
staff in the reporting
information in the new
monitoring format.
M&E
Division/
NHSRC
January
31, 2007


- 85 -


Issue Actions
Responsible
body
Time
frame
Action Taken / Current
Status
Develop TOR for
independent
management review of
process indicators
including rapid facility
assessments.
October
31, 2006

Initiate the process for
organizing regional
workshops with State /
District PMUs to
disseminate the M&E
framework and the
revised MIES format

January
2007

Confirm procurement
arrangements with UN
agencies for FY 2006.
October
20, 2006

Share draft TOR and
RFP for recruitment of
procurement agent with
development partners.
November
30, 2006

Procurement
Complete the workshop
for identified drug
inspectors in application
of guidelines for
implementing Schedule
Meetings and ensure
participation of external
experts in the inspections
for WHO GMP
certificates.
Procurement
Division
November
1, 2006

Submit acceptable audit
reports along with a
summary of eligible
expenditures, key audit
observations and action
being taken on audit
observations. Carry out a
review of the process of
appointment of statutory
auditors at the States
with reference to the
procedures in the FM
Manual.
November
15, 2006

Share FMRs for six-
month period ending on
September 30, 2006 and
MOHFW will share the
FMRs with pooling
partners in the agreed
format.
FMG and
States
(contingent
upon States
submission)
November
1, 2006

Financial
Management
Establish a system for
quarterly financial and
procurement reporting of
central activities from the
technical units to FM.
FMG Immediately

- 86 -


Issue Actions
Responsible
body
Time
frame
Action Taken / Current
Status
Develop process of a
structured management
audit with specific TOR
and outsource it to
complement the review
by FMG.

Convergence Clarify the roles and
responsibilities of ANM,
AWW and ASHAs when
planning joint activities or
seeking opportunities for
convergence.
NRHM, MH,
CH, RSS,
and Training
Divisions
















ANNEX - E

FINANCIAL MANAGEMENT

- 87 -


ANNEX - E
FINANCIAL MANAGEMENT

Progress Achieved

The progress achieved on the financial management issues and the actions taken by
MOHFW and the Financial Management Group (FMG) include:

a) Re-enforcement by FMG of the need for correct and uniform financial reporting of
expenditures in line with stated accounting policies in the FM Manual. FMG has circulated
the updated format of the FMR, which requires incorporation of opening & closing Cash &
Balances and Advances and a certification from the State Finance Manager and Project
Director. The compliance by the States, however, will need to be monitored when the 3
rd

quarter FMRs are received from the States.

b) Under NRHM, the MOHFW decided to extend the need for qualified finance staff in
all States and Districts of the country as against the initial plan which was limited to the EAG
and NE States. This has necessitated the recruitment and appointment of approx 650
finance professionals, out of which recruitment has been completed for approx 400
positions. In addition the Mission was informed that MOHFW has decided to finance
accountants in all the Blocks and at selected PHC/CHC (based on specific request from
States).

c) The FMG has completed the review of and circulated comments to the technical
divisions within MOHFW on the FMRs for the first half of 2006-07.

d) Management audits have been completed in 8 States and as agreed in the previous
Mission this is being outsourced to Institute of Public Auditors of India (IPAI).

e) Concurrent internal audit has been started in the State of Madhya Pradesh (initially to
settle accounts- advances, balances etc relating to RCH-I)

Aspects that need attention & Agreed Actions:

Finance staffing and Training:

Financial Management Group in MOHFW: Pursuant to the mandate/ responsibility of the
FMG being extended to all the projects (including disease control projects) under NRHM, the
MOHFW has sanctioned additional posts of regular government staff to the FMG. The
Mission noted that only 3 qualified consultants are in place of which two had short tenure
appointments (one contract expiring in February 2007 and the other in March 31, 2007)
which could result in lack of continuity. Given the agenda of reforms and capacity building
envisaged in the area of Financial Management across all the programs under NRHM it is
critical to have a stable core team of at least 4 qualified consultants over the next 2 to 3
years to support the Director (NRHM Finance) in implementing the reform plan.

States/ Districts: following MOHFW decision to have qualified staff in all the States and
Districts, approx 650 finance staff have to be recruited out of which approx 400 are now in
place. Large vacancies exist in the States of Uttar Pradesh, Tamil Nadu, Jharkhand, Kerala
and Jammu & Kashmir and some States in the North East. The Mission was informed that
the recruitment in Uttar Pradesh will be taken up after the State elections and is under
progress in Tamil Nadu. These States should submit a time bound action plan to complete
the recruitment and where necessary the MOHFW may consider appointing a professional
HR agency similar to the first round for EAG States.

- 88 -



Training: While some training programs have been carried out, with the large recruitment
of finance staff in the districts and blocks, there is a need to develop a structured training
plan which should include time lines, development of training modules for various levels of
staff and identification of resource persons (individuals/ institutes) and implement the same
in a time bound manner. The mission was informed that the FMG in consultation with
NIHFW is preparing a plan and the same will be developed by March 15, 2007and
implemented within 6 to 9 months.

a) Quality of the FMR and alignment with the PIP/AWPs: While the timeliness of the
submission of the FMR has improved and an analysis of the reported expenditure against
the plan has been carried out by the FMG the following concerns need to be addressed:
The reporting heads in the FMR and the PIP/AWP are not aligned resulting in
limitations in carrying out a meaningful monitoring of the approved plan versus the
actual progress (financial and physical). This is critical for the new approach (i.e.
funding of State Based Plans) under RCH-II to succeed.
The FMR format is currently is a mix of program objectives (e.g. Operationalisation of
FRUs and Expenditure on Contractual Staff). This needs to be rationalized to either
report against both (objective and natural heads) or either one of them. The Mission
was informed that the PMSG and the FMG have identified this constraint and have
circulated a revised format for discussion within the MOHFW. This is expected to be
finalized by March 2007.
A review of the first half FMR indicates that some states continue to report transfers
to lower units as expenditures (e.g. Andhra Pradesh, Chhattisgarh) and also includes
expenditures on activities such as Interventions on Geriatric, GBV and Pain &
Palliative Care Services under the head Innovations, without a budget in the AWP
(Chhattisgarh). The FMG in consultation with the technical units needs to address the
issue of accurate reporting and activities funded under RCH-II. It was agreed that (i)
this aspect of monitoring will be monitored in the December 2006 FMR and the FMG
in consultation with the technical units will, takes steps, where necessary to ensure
that these are rectified in the final FMR for the year 2006-07 (which will be
considered for the purpose of disbursement by the pooling partners); (ii) a formal
review comments will be sent to the States on a quarterly/ six monthly basis (FMG/
PMSG).
Expenditures at the central level activities (IEC etc) including central institutions such
as NIHFW are not being reported to the FMG, thereby giving an incomplete picture of
the program performance (this was also flagged off in the previous JRM).
The details of expenditure incurred on contracts above the threshold limits needs to
be reported separately as an attachment to the FMR. In order to facilitate this, the
procurement manual along-with the prior review threshold limits for procurement of
goods, works and services needs to be circulated to the States.
The 2006-07 FMR needs to be split between expenditure incurred upto Sept 30,
2006 and for the period October 06 to March 2007 to capture expenditure in the
retroactive period separately.
b) Need to improve uniformity and consistency in accounting: A review of the audit
report indicates that there is a need to improve the quality and uniformity of the annual
financial statements and the disclosures (accounting policies, notes to accounts etc). For
example expenditure by activities have not been reported by some States (e.g Orissa,
Madhya Pradesh), transfers to sub-district units are being reported as expenditures by
certain States (e.g Uttaranchal, Haryana). The FMG has prepared a revised format of the

- 89 -


financial statements which will be circulated to the States. The Mission recommends that
along-with the formats it is also necessary that:

the chart of accounts (ledger heads) as provided in the FM Manual be reviewed (and
explanations provided as to the nature of expenses to be charged to each head) to
ensure consistency and alignment with the reporting heads.
along with providing training on TALLY accounting system (as envisaged in Orissa)
in order to ensure consistency it is important that the FMG takes the lead in
designing, testing and rolling out a common chart of accounts to ensure uniformity
and consistency.
the accounting policies to be followed under the project are reinforced especially in
the area of a) grant accounting, b) capital versus revenue expenditure and c)
advances versus expenditure and ensure that the financial statement formats have a
clear disclosure of the accounting policies adopted for the preparation of the financial
statements.

c) Issues relating to quality of financial statements, disclosures and
comprehensiveness: A review of the audited financial statements for the year 2005-06
indicates the following
Some of the audit reports have a reference to the RCH-I project and Immunization
strengthening Project, both of which have closed. The new formats of audit opinion
(to include specific reference to review of procurement aspects and the change to
RCH-II) needs to be circulated to the States.
While districts are being audited, it is not clear whether district level financial
statements are being prepared and certified by the auditors. Since districts are legal
entities (registered societies) they are also required to prepare financial statements.
In addition it is observed that District financial statements have not been consistently
consolidated (i.e assets, advances and cash & bank balances etc) at the State level
to reflect the overall financial position of the State. The Mission recommends that
similar to the practice adopted under the Tuberculosis Control Project (i) first
separate audited financial statements are prepared for each district and the State
SCOVA and (ii) based on these a consolidated audited financial statement for the
project covering the State and the Districts be prepared (after eliminating inter-
society fund transfers). This would help comply with the legal requirements as well as
provide a complete picture of expenditures, advances and fund position at State and
District levels.

d) External Audit Quality and Comprehensiveness and review by FMG:

A review of the audit reports for the year 2005-06 indicates that there is a distinct
improvement in the coverage of the audit and the quality of the management letter;
however, this is not consistent across all the States. (e.g. in Orissa the auditor has
audited only the State SCOVA and relied on UC from the districts- it is not clear
whether the districts have been audited by other auditors). In line with the
recommendations under point (d) above the TOR for external audit and audit opinion
format be amended to specifically require the auditors to opine on the (i) consolidated
financial statements of the State and Districts and that they have considered all
material aspects arising from all the societies in arriving at their opinion.
While all the states (except one State) have appointed auditors from the short-listed
panel sent by the FMG, it is not clear whether the process of selection as provided in

- 90 -


the FM manual (i.e select the firm on the basis of quality rather than least cost) as
been followed. In addition the level of audit fees appears to be low compared to the
extent of the work required and the completion and submission of reports is
substantially delayed. The Mission recommends that (i) the FMG should obtain and
review whether the process adopted for selection of auditors by the States is in line
with the FM manual (i.e quality based rather than cost based); (ii) in order to ensure
timeliness consider re-appointing the same auditors for a period of 3 years, in States
where performance is rated satisfactory by the FMG; (iii) joint audit be appointed in
large States with clear allocation of districts and sub- districts and joint responsibility
for the consolidated financial statements of States and Districts.
A standard format of the management letters (internal control checklist) indicating the
issues on which the auditor needs to provide their specific comments needs to be
developed and circulated as part of the audit TOR. This is also provided in the FM
manual.

e) Management audit: the FMG has carried out management audit reviews in a few
States and the quality of the report is good, especially the feedback to the Secretary and as
agreed in the previous mission this is being outsourced to IPAI. In order for this to be
effective it is important that (i) a formal entry and wrap up discussion is had with the Project
Director and Health Secretary, to share the objectives & findings from the management audit
and agree on actions & timelines to address the critical weaknesses, if any. The key cross
cutting issues should be identified for action by the FMG and shared with the other States
and pooling partners during the JRMs.

f) Need to strengthen internal control & institute a system of internal audit the
management letters from the external auditors indicate the need to significantly strengthen
internal control especially at the districts, sub- districts and below. The key issues emerging
are:

Need for closure of multiple bank accounts
Failure to carry out regular reconciliation of the bank accounts and settle accounts
relating to old programs
Practice of funds being transferred to the bank accounts of CMHOs and other field
level functionaries.
Advances pending settlement with various agencies and individuals (eg Madhya
Pradesh has approx Rs 40 crores of advances) and delay in submission of financial
reports/ UC against funds advanced to blocks, PHC/CHC and ANMs and the varying
quality of the documentation
Inadequate/ incomplete documentation to support the cash grants against JSY and
compensation for sterilization (as noted in Haryana).

Given that approx Rs 4000 crores (RCH/ NRHM Flexipool funds) is flowing to the States, it is
necessary that a system of concurrent/ internal audit for the districts and sub-districts is
instituted- similar to the practice adopted by Madhya Pradesh in FY 2006-07. The Mission
agreed that this will be extended to all the major States and started at the district and sub-
district level. For this, a specific TOR will be prepared and circulated by the FMG (along-with
appointment process and reporting format). The TOR should include a sample physical
verification of PHC/CHC and sub-centres, review of NGO contracts and beneficiaries under
JSY etc.














ANNEX F

STATE REPORTS


- 91 -


RCH II: FINDINGS OF 3
rd
JRM

ANDHRA PRADESH

Impressive range of innovative strategies being implemented to meet RCHII goals coupled
with relatively better health seeking behaviour augurs well for the future. Reasons for low
fund utilization (0%) in child health during FY 06-07 are not clear. The states TFR of 1.8 is
the lowest in the country. The major challenge for Andhra Pradesh is to upgrade the quality
of services and sustain service levels.

Financial progress
(05-06) (06-07)
Allocation Rs. 90.50 Crores Rs. 135.57Crores
Release Rs. 58.85 Crores
Rs. 94.09 Crores
(till Sept 30, 06)
Reported Expenditure Rs. 51.33 Crores
Rs.50.42 Crores
(till Sept 30, 06)
Expenditure/ Release 87 % 54%
Expenditure/ Allocation 57% 37%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
1,100 hospitals
accredited for JSY
Birth waiting homes
under construction for 27
tribal hospitals
Wide publicity for tribal
JSY

CHILD HEALTH
46% children fully
immunised
Young infant health
insurance scheme in
place
IMNCI training in one
district completed
Health and nutrition day
conducted in every
village once a month

Look closely into the
utilisation under child
health as there has been
0% expenditure under the
head in FY 2006-07

- 92 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
Ensure that the
beneficiary is instructed
about the proper use of
the newborn care kit.
Ensure proper
maintenance of Cold-
Chain/Vaccine Stores in
all districts

GOVERNANCE
Expedite the process of
recruiting ANMs
ANM recruitment under
process against the
requirement of 3864
ANMs

Need to explore
possibilities of NGOs
providing doctors for
MMUs
State is working out the
possibility to link with
private medical colleges
to resolve the demand of
doctors in MMUs.

Need to rationalize staff
all across the state

Available manpower
against requirement:
o Specialist=26%
o Paediatrician=
20%
o Staff Nurse=
100%
77 lady MBBS doctors
available

TRAINING/ IEC/ NGO INVOLVEMENT
Give doctors training on
skilled birth attendance
and anesthesia.
Try to keep track of the
trained doctors and place
them in facilities where
their skills are utilised
100% WHV (ASHA)
trained (55,904)
EmOC training with
FOGSI
IMNCI training with IAP
Academy of nursing
studies for ANMs
training
SBA training in all
districts
Other trainings
conducted includes:
EmOC, EmPedCare,
EmAnesth.

Need to put more effort on
IEC of Emergency
contraceptive pills,
especially at community
level


- 93 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
INNOVATIONS
Health information help
line through PPP
Urban health centres
through NGOs
Universal health
insurance scheme


EQUITY AND ACCESS
Rural emergency health
transport scheme under
PPP; total 432 rural
ambulances w.e.f. April
2007
56 MMU functional since
January 26, 2007


OTHER ISSUES
12,522 SCs functional
with ANMs
90% of the SCs sent UC
for untied funds
Health Melas conducted
regularly
33% of PHCs working as
24x7


Try to conduct all the
targeted health melas by
31
st
March 2007.


- 94 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 80%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
CFW & AO
3 % of sampled state and district programme managers aware of
their responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
100%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves

0%
0%
0%
6 % of districts reporting quarterly financial performance in time 100%
7 % of district plans with specific activities to reach vulnerable
communities
100%
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
100%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
100%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 50%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 67%
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
100%
13 M & E Triangulation --

- 95 -


RCH II: FINDINGS OF 3
rd
JRM

ANDAMAN AND NICOBAR ISLANDS

Andaman and Nicobar Islands TFR at 1.9 (SRS, 1998) is among the best in the country.
The IMR (SRS 2005) of 27 is considerably lower than the national average of 58. A&N
Islands has already achieved the 10th plan goals (2007) for IMR and TFR. When compared
with the national figure, A&N Islands is doing very well in skilled care at birth (77.9%) and
institutional deliveries (75.5). Immunization coverage (children 12-23 months) is 69.3%,
much better than the national average of 45.8%. The contraceptive prevalence for female
sterilisation (44.7%) and contraceptive prevalence rate for any modern method (57.3%) is
also very encouraging. But under RCH II, the UTs progress could be very much better. A&N
Islands has conducted several trainings, but ground level implementation needs to be
strengthened.

Financial progress
(05-06) (06-07)
Allocation Rs. 0.5 Crores Rs. 0.8 Crores
Release
Rs. 0.44 Crores Rs. 0.48 Crores
(till Sept 30, 06)
Reported Expenditure
Rs. 0.25 Crores Rs. 0.15 Crores
(till Sept 30, 06)
Expenditure/ Release 57% 31%
Expenditure/ Allocation 50% 19%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH

60 ASHAs have been
placed in the district of
Nicobar
20 dais have been trained
in SBA
Imprest money of Rs.5000
has been provided to the
ANMs of the Sub Centers
for JSY disbursement.








Design an effective
system to monitor timely
payment of the JSY
beneficiaries.
FAMILY PLANNING
2 sterilization camps have
been held
The state needs to focus
on NSV and IUD
Try to improve the
awareness of EC through
campaigns
GOVERNANCE
The state needs to
immediately send the
pending UCs to the

- 96 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
centre.
TRAINING/ IEC/ NGO INVOLVEMENT
Under RCH II, the UT has
already conducted:
o Nukkad Nataks:05
o Healthy Baby Shows:20
o Breast Feeding Week: 20
Camps
o Motherhood Day: 15
Camps
o Nutrition Week: 20 Camps
o Display of Boards: 25
Places
o Outdoor Exhibitions: 2

Trainings conducted under
RCH II:
MTP training for MOs
Minilap training for MOs
IUD insertion training for
paramedics
Integrated skill training for
ANMs/LHVs/male health
workers/MOs/SNs.

OTHER ISSUES
Try to conduct all the
targeted health camps by
31
st
March 2007.

- 97 -

RCH II: FINDINGS OF 3
rd
JRM

ARUNACHAL PRADESH

Arunachal Pradesh has not been able to sustain the progress made during the 2
nd
JRM. The
state needs to overcome several challenges, which has affected the pace of implementation.
There is an urgent need to address the perennial problems of lack of skilled manpower,
training resources through strategic planning and management. Manpower planning is the
need of the hour. Collaboration with RRC-NE and the development partners could be the
way ahead. The state needs to expedite fund utilization on operationalization of facilities and
training.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 7.35 Crores Rs. 5.25 Crores
Release Rs. 7.35 Crores
Rs. 3.20 Crores
(till Sept. 30,06)
Expenditure
Rs.4.39 Crores
Rs. 3.74 Crores
(till Sept. 30,06)
Expenditure/ Release 60% 117%
Expenditure/Allocation 60% 71%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Train ASHA in home
based delivery services
and link them to health
facilities
Sensitize MOs and
ANMs to assist ASHA
CHC and PHCs to be
provided managerial
service
136/378 SCs fully
functional
Operationalised 10
FRUs (DHs)
10/31 CHCs upgraded
to IPHS standards.
45/50 upgraded PHC
upgraded to 24x7


7/12 facilities
functional
Lack of specialists for
FRU

Ensure fully
functional facilities by
1
st
April
Plan for ensuring at
least one functional
district hospital
Slow progress of JSY Promote JSY through
IEC/ BCC
Immunization coverage
(28.4%, NFHS 3) is poor
Organise monthly village
health days regularly
Focus on outreach
sessions

- 98 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
CHILD HEALTH
Plan for IMNCI strategically.
Undertake phase wise
training of limited batches
for qualitative outcome
7/60 NBCC functional in
DHs

TRAINING/ IEC/ NGO INVOLVEMENT
Conduct needs assessment
for capacity building of
technicians, for FRUs
Link trained health
personnel to health facilities
State level training of
SBA completed
Delay in trainings of para
medical staff

INNOVATIONS

EQUITY AND ACCESS
Improve access to basic
services through ARMY-
State partnership

OTHERS
Prioritize identification and
appointment of skilled
manpower
Lack of skilled manpower
in facilities
Strategic planning for
rationalising manpower
Develop a nurses cadre
Low fund utilization(no
utilization for dai training,
operationalization of
facilities)
Expedite fund utilization
for technical interventions


- 99 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 100%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
a. 100
b. 100
3 % of sampled state and district programme managers aware of
their responsibilities
100
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
0
5 % of district not having one month stock of
d. Measles vaccine
e. OCP
f. Gloves
<10%
6 % of districts reporting quarterly financial performance in time 75%
7 % of district plans with specific activities to reach vulnerable
communities
-
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
75
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
15%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 30%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 100%
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
43%
13 M & E Triangulation

- 100 -


RCH II: FINDINGS OF 3
rd
JRM

ASSAM

Assam has demonstrated steady progress over the last two JRMs.There been significant
improvement in the implementation of technical interventions. Program management
systems are in place and institutional revamping has been completed. Immunization and
allied services have been promoted through extensive IEC activities. However, the quality of
implementation needs to be focused especially in rural areas. There has been minimal
headway on interventions pertaining to vulnerable groups. Capacity building of technical staff
is behind schedule. The health facilities need to be adequately equipped to cater to the
increasing demand for services from the community. HMIS and logistics management needs
to be fast tracked to accelerate program quality. Fund disbursal and management at the
district and block levels needs to be streamlined.
Financial progress
FY 05-06 FY 06-07
Allocation Rs. 116.05 Crores Rs. 110.7 Crores
Release Rs. 64.91 Crores
Rs. 21.84 Crores
(till Sept.30, 06)
Reported Expenditure Rs. 3.72 Crores
Rs. 12.13 Crores
(till Sept.30, 06)
Expenditure/ Release 6% 55%
Expenditure/ Allocation 3% 11%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Ensure that RKSs are fully
functional
Intensive monitoring of RKS
Community to become
active participants

Facility survey of 93
CHCs & 20 DHs-
completed
5 districts chosen for
SBA. SBA training
undertaken in 11 districts

24000 ASHAs selected

Training of 14030 ASHAs
completed
Ensure ground level
training of ANMs

Utilize skills of
experienced TBAs for
improving service
delivery





8201 health days
organised in each
Anganwadi centers
Health days organized by
ASHAs

Monitor health days by
District Media officer
Organize school health
programmes

Second ANM has been
appointed in 1800 sub
centers
Improved performance on
institutional deliveries
Appoint second ANM in
all SCs, preferably a
male worker

- 101 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
CHILD HEALTH
Immunization promoted
through IEC. Third round
of immunization
completed

11 National trainers
trained in IMNCI, 23 for
State TOT


FAMILY PLANNING
25 doctors trained in NSV
GOVERNANCE
Appointment of all staff and
their training should be fast
tracked. In the case of
accounts staff, consider
appointment of commerce
graduates and provide in
depth training
SPMU staff appointment
completed and 23
DPMUs are in place.


TRAINING/ IEC/ NGO INVOLVEMENT
Health day should be
utilized to disseminate IEC
In keeping with the local
practice of tobacco and
betel nut consumption of the
women specially in the
State, awareness and anti-
tobacco campaign needs to
be aggressively launched

Utilize the services of local
TV channels to disseminate
messages to the community

BCC activities should be
evaluated for impact/
behaviour change.
















Prepare specific IEC for
malaria intervention,
family planning and child
health
Prioritize training needs
urgently
No progress on multi skill
training of doctor
Expedite multi skill
training of MOs at the
earliest
Selection of MNGO is slow
and should be completed by
December
NGOs and PRIs involved
in program
implementation
12 MNGOs selected in
14 districts


- 102 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
INNOVATIONS
Explore the scope of an
Army-Health department
partnership for better
access of community to
hospital facilities.

Planning for PPP with tea
garden hospitals and
army hospitals

EQUITY AND ACCESS
Special strategies for VGs 4058 PRIs trained in
SIRD
OTHERS
Verify and collect data
from ANM (for IEC and
MIS) in monthly
meetings. PHCs collate
the data at their end.
RRC needs to introduce
and orient user groups
on new formats for MIS
in block s/ districts

Operationalise MIS on a
priority basis
Orient staff on new M & E
formats


- 103 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 111.61%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
88.89 %

3 % of sampled state and district programme managers aware of
their responsibilities
100%

4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
State: 100%
District: 100%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
6 % of districts reporting quarterly financial performance in time 95.65 %
7 % of district plans with specific activities to reach vulnerable
communities
100%
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
100%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures

10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 56.66 %
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 31.07 %
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
RTI/STI health
facilities
available in all
the 149 BPHCs,
93 CHCs &
FRUs, 3 SDCHs
& 20 DHs
13 M & E Triangulation


- 104 -


RCH II: FINDINGS OF 3
rd
JRM

BIHAR


Bihar has undertaken initial steps for implementation of RCH II. State has focussed on areas
of rationalising staff, recruiting manpower for vacant positions, and strengthening/
operationalising facilities. For getting results, the state needs to impart adequate focus better
utilisation of the resources available for improving outcomes related to MH, CH and FP
interventions, particularly for increasing immunisation, and in reducing anaemia of pregnant
women and children.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 128.50 Crores Rs. 140.99 Crores
Release Rs. 29.38 Crores
Rs. 95.07 Crores
(till Sept 30, 06)
Reported Expenditure Rs. 3.67 Crores
Rs. 4.95 Crores
(till Sept 30, 06)
Expenditure/ Release 12 % 5%
Expenditure/ Allocation 3% 4%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Complete manpower mapping
of FRUs done
PMCH developed as Nodal
Training Centre, 4 master
trainers trained in CMC
Vellore by FOGSI

Orientation of 50 district
trainers for SBA in 11 districts
completed at SIHFW
Orientation of 88 MOICs in
these districts also completed
Rate contract of stethoscope
and weighing machines
finalized,12000 each being
procured

Registrations under JBSY
since July06 171352, no. of
institutional deliveries 41222
Impart greater focus to
institutional deliveries
under JSY
CHILD HEALTH
TOT of Master trainers
completed for 6 districts 44
trainers
IMNCI training calendar
Appointed state
immunisation officer

- 105 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
finalized and funds sent to all
the districts
So far 47 doctors, 148
ANMs/paramedics and 631
AWWs trained
Availability of manpower and
availability of drugs, etc.
need to be synchronised
Outbreak of Kala Azar
disease needs to be mapped
and tackled.

FAMILY PLANNING
51703 sterilizations done in
this year.
Target of 1,80,000 for 06-07
far higher than last years
achievement of 83,509
ASHAs, health camps to
be used to propagate
spacing methods
GOVERNANCE
State to closely monitor
recruitment and effective
deployment of DPMU staff.
Need to ensure clarity of
roles and reporting
relationships and identify
steps for effective integration
of DPMU staff into the health
department.
Roles and responsibilities of
DHS consultants clarified
Supportive Review meetings
of DPMs being held every
month at SHSB

All DHAPs to be
prepared by March
2007.
District staff including
DPMUs to be actively
involved in preparation
of DHAPs, and
prescribed process of
block and district level
consultations to be
followed.
ANMs to be delegated
powers for utilising untied
funds at SHCs.

TRAINING/ IEC/ NGO INVOLVEMENT
SIHFW to be strengthened/
operationalised.

Apart from training,
Knowledge/ skill base of
ANMs to be improved. They
should be given required
instruments like BP
instrument & weight
machines.
State could consider PPP for
Training schools


- 106 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
62% ASHAs trained
Facility survey of 20 ANM, 1
GNM and 1 LHV school
completed
Trainings started in 6
ANMTCs
Use NGOs for training
ASHAs
Carry out IEC for
institutional delivery,
PNDT and health camps
IEC messages need to
be in sync with services
delivered/
operationalised facilities
UCs/financial reporting
on IEC to be
streamlined
INNOVATIONS
The innovative schemes
need to be evaluated

EQUITY AND ACCESS
RKS should subsidise/
provide free tests for BPL
patients

Incentives to be paid to
ASHAs for their services

Data provided by the data
centre needs to be validated
and analysed. Disaggregate
data in terms of SC/STs to
be made available.
State to provide documentary
evidence for achievement of
core 13 indicators as
specified in Enclosure 4 of
the JRM Process Manual
(see below)

OTHERS
An incentive mechanism
needs to be developed for
MOs to keep them motivated.
Mobile boat clinics could be
considered for villages
situated on riverbanks.

Institutions to be made eco
friendly through water
harvesting structures and
use of local material with
focus on utility. Construction
and maintenance of toilets
for inpatients as well as
visitors at health facilities to
be given focus.
Upgraded 600 PHCs to 30
bedded hospitals
Repair/renovate staff
quarters
Make available clean
toilets at camps.

- 107 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
Organise monthly village
health days at AWCs
Procure and distribute
ASHA kits
Provide pregnancy
detection kits to ASHAs
Use PRIs/ monitor
PNDT cases panchayat
wise
Monthly meetings at
PHCs to be used for
collecting and
crosschecking reports of
ANMs
Review outcomes of
districts with CMHOs on
periodic basis
Strengthen LHV cadre.
Carry out adhoc
promotion of ANMs, if
mandatory training is
pending.
Strengthen nursing
cadre. Appoint,
nominate nodal persons
for this at state, district,
blocks
Recruit MPW (M) for
carrying out activities
related to disease
control programmes.


- 108 -


RCH II: FINDINGS OF 3
rd
JRM

CHANDIGARH


Financial progress
FY 05-06 FY 06-07
Allocation Rs. 1.00 Crores Rs. 1.23 Crores
Release
Rs. 0.74 Crores Rs. 0.82 Crores
(till Sept 06)
Reported Expenditure
Rs. 0.32 Crores Rs. 0.23 Crores
(till Sept 06)
Expenditure/ Release 43% 28%
Expenditure/ Allocation 32% 19%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
CHILD HEALTH
Mandatory Immunisation
cards for admission to
government and private
schools

FAMILY PLANNING
Fixed day sterilisation
services being provided at
health facilities

OTHERS
PNDT enforcement is
lacking. Needs to be
addressed.
Slums areas have very
poor services and
need focus.


- 109 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 82%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
3 % of sampled state and district programme managers aware of
their responsibilities
---
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
---
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
6 % of districts reporting quarterly financial performance in time 100%
7 % of district plans with specific activities to reach vulnerable
communities
---
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
100%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
100%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month ---
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 100%
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
100%
13 M & E Triangulation ---


- 110 -


RCH II: FINDINGS OF 3
rd
JRM

CHHATTISGARH


Chhattisgarh needs to consolidate the initial progress made in terms of institutional
structures, recruitment and training of grass root worker (Mitanins). Some of the areas
requiring attention are programme monitoring, manpower planning, and block level
programme management structures. The state needs to impart focus on outcomes, also
revise the goals for IMR from targeted 35 by 2012 to <30. Institutional deliveries in particular
need to be given a greater push in the state.

Financial progress
FY 05-06 FY 06-07
Allocation Rs.32.50 Crores Rs. 42.53 Crores
Release Rs. 27.46 Crores
Rs. 30.00 Crores
(till Sept 30, 06)
Reported Expenditure Rs. 65.61 Crores
Rs. 31.10 Crores
(till Sept 30, 06)
Expenditure/ Release 239% 103%
Expenditure / Allocation 201% 73%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Widely Disseminate clear
information on JSY at all
levels using innovative
strategies.
To explore PPP mechanism
to recruit contractual staff
and make the urban health
centres more functional.
Develop operational
guidelines in local language
to systematically set up
systems/ process to prevent
infection and manage health
care waste based on the
national IMEP framework
Incentives for FRUs/CHCs
and PHCs for conducting
institutional deliveries
JSY implemented in all the
districts, till date 43008
women benefited from the
scheme.

More focus required
on institutional
deliveries
CHILD HEALTH
Create Level II Sick Newborn
Care Units (SNCU) in each
District Hospital and Medical
College Hospital and
Stabilisation Units at block
level in districts with high
IMR.
Pilot the IMNCI in 3 identified
districts in a phased manner
Incentive for Mitanin to
mobilise people for
immunisation & ANC as well
as all other national
programmes
Realign the targeted
IMR to be in line with
national target of < 30
by 2012

- 111 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
and conduct IMNCI training
based on the national
framework guidelines.
Carry out biannual Vitamin A
supplementation with
deworming in all the children.
FAMILY PLANNING
PFIs services being used for
FP trainings

ARSH
To implement the adolescent
health programme as
budgeted in the PIP.
Conduct block level training
of counsellors and peer
educators

GOVERNANCE
Fill the posts (medical,
paramedical and non-
medical)
Develop a consistent policy
for rational resource
deployment based on
mapping of human and
infrastructure resource gaps.
The vacancies for accounts
officers at district level should
be filled on priority
200 PHCs and 16 CHCs to be
operationalised in the year.2
MOs per PHC, and BMO, 2
MOs and 4 specialists per
CHC sanctioned.
81% ANMs & LHVs, 70%
MPW & supervisors, 525 MOs
and 29% specialist positions
filled.
Plan for manpower at
newly created facilities
Block level
programme managers
to be appointed
Strengthen RD office
for monitoring the
programme
DAPs finalised and appraised
for all 16 districts.
Work on preparation of block
and village level plans
underway.

FINANCIAL MANAGEMENT
GoI to ensure timely release
of advance funds for
mandatory activities (JSY,
sterilisation compensation
etc.)
State should reflect the
amount received, released
and actual expenditure
incurred.
Provide at least provisional
UCs on 1st year funds, in
order to access 2
nd
year
funds.
Develop mechanism for
sanctioning funds by CMO
Districts being provided funds
based on their appraised
DAPs


- 112 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
up to a ceiling in the absence
of the DM to avoid delays.
Disseminate guidelines on
utilisation of untied funds to
various levels
TRAINING/ IEC/ NGO INVOLVEMENT
Combine different trainings
Integrate courses for
paediatrics, management
RTIs/STIs, IMNCI, MTPs in
the training courses for
multiskilling.
Development partners to
help in upscaling IMNCI and
SBA, EmOC, Anaesthesia
training.
Finalise the setting up of
SIHFW and carry out training
audit at regular intervals.
SIHFW made functional
All TOTs except IMNCI
planned for the year have
been completed
SBA and skill upgradation
training for ANMs ongoing in
64 FRU blocks

Develop nursing cadre
in the state

Conduct orientation
programmes to medical and
non-medical personnel on
the new schemes and
programmes including skill
based trainings
Fill the remaining posts at
district and block level and
conduct need-based training

Implement the integrated,
comprehensive IEC strategy
at all levels
Mitanin Communication toolkit
under preparation.
The State BCC strategy/
implementation framework
(Samagra Sanchar Niti) ready

INNOVATIONS
Disseminate consistent and
clear guidelines about
Jeevan Deep Samitis (Rogi
Kalyan Samiti) at all levels
Expand the composition of
the JDS to make more citizen
oriented
Explore partnerships with
private sector to address
manpower and shortages
and increase the outreach
services
SIHFW supporting Jeevan
Deep initiatives, Swasth
panchayat and BCC activities


- 113 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
EQUITY AND ACCESS
Map health indicators and
resource gaps and develop a
strategy to match resources
with need. Define clear
criteria for resource
allocation.
Define and disseminate a
clear policy on User fees and
exemptions based on poverty
levels.
Develop standardised health
registers at the facility levels
recording disaggregated data
in terms of SC/ST

M&E AND TA
Need to develop a HMIS
from district to state level
Develop standardised and
uniform registers for inpatient
records at the primary facility
levels e.g. admission,
discharge, delivery and death
Capture and report
disaggregated data on
process and outcome
indicators
OTHERS
Systematic quarterly
meetings should be held to at
village level between
PRI/AWW/ ANM/ Mitanin to
plan and monitor work plans
DWCD and PHED to jointly
construct toilet/ water
facilities in the Anganwadi
centres wherever required.
To coordinate with DWCD to
develop a mother and child
protection card with a growth
chart
Increase convergence with
Malaria Control Programme
Develop insurance
scheme for BPL
families
Ensure Mitanin gets
incentives on time.



- 114 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 80%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
90%
3 % of sampled state and district programme managers aware of
their responsibilities
80%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
60%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
<10%
6 % of districts reporting quarterly financial performance in time 80%
7 % of district plans with specific activities to reach vulnerable
communities
80%
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
80%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
80%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 50%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 50%
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
60%
13 M & E Triangulation



- 115 -


RCH II: FINDINGS OF 3
rd
JRM

DADRA & NAGAR HAVELI


Financial progress
FY 05-06 FY 06-07
Allocation Rs. 0.50 Crores Rs. 0.70 Crores
Release
Rs. 0.35 Crores Rs. 0.30 Crores
(till Sept 06)
Reported Expenditure
Rs. 0.17 Crores Rs. 0.12 Crores
(till Sept 06)
Expenditure/ Release 49% 40%
Expenditure/ Allocation 34% 17%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Only one CHC which
needs to be made fully
functional.
GOVERNANCE
Mission Steering Group
meetings are irregular.
District Mission meetings
are not being held.
Ensure regular meetings.
TRAINING/ IEC/ NGO INVOLVEMENT
No training institute
available.
Gujarat state can be
requested to provide
assistance.
EQUITY AND ACCESS
25 ASHAs recruited for
tribal areas.
TOT for ASHA master
trainer done.
Mobile medical units are
being organised.

OTHERS
Monthly VHN days being
conducted in all AWWs.



- 116 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 80%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
---
3 % of sampled state and district programme managers aware of
their responsibilities
---
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
---
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
6 % of districts reporting quarterly financial performance in time 100%
7 % of district plans with specific activities to reach vulnerable
communities
---
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
100%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
100%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month ---
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services ---
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
85%
13 M & E Triangulation ---


- 117 -


RCH II: FINDINGS OF 3
rd
JRM

DAMAN AND DIU


Daman and Dius IMR (SRS 2005) of 28 is considerably lower than the national average of
58, but TFR at 2.5 (SRS, 1998) needs more attention. The UT has a very high population
density (1412 per sq km), but has a very small population of 1.58 lakhs; this should make the
project implementation much easier in the region. The UT needs to have more effective
strategies to reduce the total fertility rate. The UT has been spending a lot of money in
IEC/BCC and civil works.

Financial progress
(05-06) (06-07)
Allocation Rs. 0.5 Crores Rs. 0.72 Crores
Release Rs. 0.23 Crores Rs. 0.41 Crores
(till Sept 30, 06)
Reported Expenditure Rs. 0.43 Crores Rs. 0.15 Crores
(till Sept 30, 06)
Expenditure/ Release 187% 37%
Expenditure/ Allocation 86% 21%


Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH

54 ASHAs have been
placed in all the villages
Low utilisation of JSY
beneficiaries as the UT
has only 256 BPL family
and 12% tribal
population.

Train the ASHAs as soon
as possible.
Make sure that these
beneficiaries get the full
benefits of JSY in time.
CHILD HEALTH
Routine Immunization
services strengthened by
involving link worker in
industrial area.

FAMILY PLANNING
Need to formulate
strategies to bring down
the TFR
GOVERNANCE
District Health Society
and District Health
Mission registered.


- 118 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
TRAINING/ IEC/ NGO INVOLVEMENT
Daman and Diu is co-
ordinating with NIHFW
Ahmedabad to conduct
NSV training for the
M.O.s.

INNOVATIONS
Garba on wheel has
been carried out as an
innovative IEC campaign
on reproductive & safe
motherhood issues
during navratri festival

OTHER ISSUES
Try to conduct all the
targeted health camps by
31
st
March 2007.



- 119 -


RCH II: FINDINGS OF 3
rd
JRM

DELHI


Delhi has the highest density (9339) of population in India; in addition it has mostly urban
population (93.2%). Delhis TFR at 2.1 is very encouraging. The IMR (SRS 2005) of 35 is
considerably lower than the national average of 58. In maternal health, the proportion of
women getting full antenatal care in Delhi (36.2%) has a definite scope of improvement.
Delhi does not have very encouraging figures in terms of skilled care at birth (59.9%) and
institutional deliveries (49.9%). Delhi has been a late starter in RCH II, but now they have
picked up the momentum. But, sex ratio along with institutional delivery is still a big
challenge for the state.

Financial progress
(05-06) (06-07)
Allocation
Rs. 16.50 Crores Rs. 18.71 Crores
Release
Rs. 7.27 Crores Rs. 9.14 Crores
(till Sept 30, 06)
Reported Expenditure
Rs. 3.29 Crores Rs. 1.22 Crores
(till Sept 30, 06)
Expenditure/ Release 45% 13%
Expenditure/ Allocation 20% 7%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
State to act quickly on
implementing JSY. Focus
on slum areas/ families
opting for home deliveries
through appropriate BCC

Monthly health day to be
convened regularly and
quality ensured through
trained and well equipped
staff.


JSY implementation
started




22 health days have
been convened during
the 3
rd
quarter.
38 RCH camps held
between Oct. and Dec.
2006.


CHILD HEALTH
4 batches of ANM/LHV
comprising 15 in each
batch imparted trainings
in Safe Immunization
Practices including Hand
on training. 14 more
batches planned in
current financial year.


- 120 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
Trainings funded through
state plan scheme on
immunization
Mobility support provided
to each district for
monitoring of
immunization sessions
and feed back given and
corrective actions
recommended

FAMILY PLANNING
NSV week held in 15
hospitals

141 NSVs conducted


GOVERNANCE
SPMU/DPMU staff needs
to be appointed on
priority. State should
closely follow up with
HSCC to ensure that
recruitment takes place on
time.
Advertisements given for
recruitment of
SPMU/DPMU staff

TRAINING/ IEC/ NGO INVOLVEMENT
State should move away
from Dai training and
focus on training SBAs
SBA training module
circulated, training to
start from February 2007
RCH workshop
conducted in 6 districts
for MOs, ANMs, PHNs
and SNs
6 MNGOs selected for 8
districts



EQUITY AND ACCESS
For transport of obst.
emergency cases, Delhi
has tied up with CATS
ambulances to provide
24 hrs ambulance
services.

OTHER ISSUES
All cases of PNDT very
old and no one attending
to these cases. State to
follow up and ensure
prosecution to convey the
1548 inspections have
been conducted under
PNDT
Under PNDT, 74-show
cause notices have been
Delhi needs to be very
aggressive to improve the
sex ratio of the state.



- 121 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
right message to all
concerned.
issued between October
and December 2006.
2 prosecution have been
made under PNDT





Try to conduct all the
targeted camps by 31
st

March 2007.



- 122 -


RCH II: FINDINGS OF 3
rd
JRM

GOA

With TFR of 1.8, IMR of 16, 92.6% institutional deliveries and 94.3% skilled birth attendance,
Goas main challenge is to sustain service levels and ensure that the needs of the unserved
are catered to. The state has already achieved the national RCH goal 2010 for IMR and
TFR. Being a small state with excellent socio-economic indicators it is expected that Goa
would be one of the first to achieve NRHM goals. The state could consider administrative
decentralization to panchayats, rationalization of staff and strengthening of nursing cadre.
During JRM 3, Goa mostly focused on infrastructure strengthening and training. The state
needs expedite the implementation of RCH II strategies.

Financial progress
(05-06) (06-07)
Allocation Rs. 1.50 Crores Rs. 1.92 Crores
Release
Rs. 1.05 Crores Rs. 0.45 Crores
(till Sept 06)
Reported Expenditure
Rs. 0.28 Crores Rs. 0.25 Crores
(till Sept 06)
Expenditure/ Release 27% 56%
Expenditure/ Allocation 19% 13%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Need to identify pockets
of underserved population
groups
Skilled Birth Attendance
(SBA) After
sensitisation of state
officers at NIHFW
sensitisation of district
trainers is completed and
training of staff nurses in
SBA in district hospital is
initiated.
Training in RTI/STI case
management is
conducted for medical
officers.
Rs. 1.19 lakhs of
allocated 8 lakhs has
been spent on JSY till
second quarter of FY
2006-07
Consider the suggestion
of previous JRM
mentioning the need to
identify pockets of
underserved population
groups.
CHILD HEALTH
Training in IMNCI: State
level trainers are
identified. However,
training of trainers is not
State must expedite TOT
for IMNCI.

- 123 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
taking off. A state level
meeting of stakeholders
is planned in Feb. 07.

FAMILY PLANNING
Training in Laparoscopic
sterilisation and training
in MVA technique for
MTP to be conducted by
SFWB Maharashtra.
One surgeon
successfully trained in
NSV.
Trainings needs to be
conducted as soon as
possible


More surgeons needs to
trained in NSV.

Try to improve the
awareness of EC through
campaigns
GOVERNANCE
Training of District Prog.
Managers conducted at
SIHFW Nagapur has
been completed by three
officers.

Try to put SPMUs and
DPMUs in place by 31
st

March 2007.
TRAINING/ IEC/ NGO INVOLVEMENT
A proposal for
establishing state
institute of Health &
Family Welfare is moved
to the government.

EQUITY AND ACCESS
Try to recruit link workers
(equivalent to ASHA) in
tribal areas
OTHER ISSUES
Try to conduct all the
targeted camps by 31
st

March 2007.


- 124 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 97.7%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
NA
3 % of sampled state and district programme managers aware
of their responsibilities
NA
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
NA
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
6 % of districts reporting quarterly financial performance in time NA
7 % of district plans with specific activities to reach vulnerable
communities
NA
8 % of sampled outreach sessions where guidelines for AD
syringe use and safe disposal followed
100%
9 % of sampled FRUs following agreed IP and health care
waste disposal procedures
100%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per
month
31%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services NIL
12 % of sampled health facilities offering RTI/ STI services as
per the agreed protocols

13 M & E Triangulation


- 125 -


RCH II: FINDINGS OF 3
rd
JRM

GUJARAT

Gujarat has shown impressive progress with a wide range of innovations especially in the
area of HR planning, e.g. use of ISM doctors in rural areas and involving private practitioners
for EmOC and professionals from medical colleges for training. The Chiranjeevi and Vande
Mataram scheme appears to be highly promising. Gujarat may share their success stories
with other states.

Financial progress
(05-06) (06-07)
Allocation Rs. 60.50 Crores Rs. 81.41Crores
Release Rs. 33.83 Crores
Rs. 49.35 Crores
(till Sept 30, 06)
Reported Expenditure Rs. 22.12 Crores
Rs. 9.44 Crores
(till Sept 30, 06)
Expenditure/ Release 65% 19%
Expenditure/ Allocation 36% 12%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Vande Mataram scheme
for ANC
Chiranjivi scheme for
institutional delivery
48840 JSY beneficiaries

CHILD HEALTH
Micro plan for UI
operationalised
Guidelines for UI provided
IMNCI training in 9 districts
Neonatal resuscitation kits
procured

GOVERNANCE
100% SPMUs and DPMUs
in position

2DHAP submitted to GoI
and 10 under scrutiny at
state level

TRAINING/ IEC/ NGO INVOLVEMENT
FOGSI and pvt. Medical
college involved for training
HMIS training for districts
by FRHS
Training completed over
targeted:
- SBA: 125%


- 126 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
- BEmOC-MO: 100%
- BEmOC-SN: 100%
- CEmOC- MO
(FRUs): 113%
- LS anaesthesia
skill: 32%
- STI/RTI: 44%
- MTP: 38%
Films on PNDT, MH,CH
Posters, PVC stickers,
acrylic boards for all
CDHOs
250 BIECOs and 100
BHOs trained at MICA for
specialised BCC training

19 MNGOs for 23 districts.
INNOVATIONS
ISM doctors placed in
PHCs for 24x7

EQUITY AND ACCESS
85 MMUs operational
OTHER ISSUES
Establishment of AFHS at 6
medical colleges, 18 DH,
12 CHCs and 12 PHCs

Gujarat may share
their success story
with other states


- 127 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 88%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
100%
3 % of sampled state and district programme managers aware
of their responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
100%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves

0%
0%
0%
6 % of districts reporting quarterly financial performance in time 100%
7 % of district plans with specific activities to reach vulnerable
communities
100%
8 % of sampled outreach sessions where guidelines for AD
syringe use and safe disposal followed
80%
9 % of sampled FRUs following agreed IP and health care
waste disposal procedures
100%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per
month
40%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 32%
12 % of sampled health facilities offering RTI/ STI services as
per the agreed protocols
60%
13 M & E Triangulation


- 128 -


RCH II: FINDINGS OF 3
rd
JRM

HARYANA

Recent survey data show a good performance on MMR; however IMR and TFR are quite
high. With MMR of 162 (SRS 2001-03), Haryana has already achieved the 10th Plan (2007)
goal of 200. IMR (SRS 2005) of 60 and TFR of 2.7 (NFHS 3, 2005-06) are quite high and
nowhere near the corresponding 10th Plan (2007) goals of 45 and 2.3 respectively.
However, Haryana has shown good progress on implementing RCH strategies. Upscaling of
innovations such as Delivery Huts and the Vikalp Scheme are positive steps. Additionally,
the state has put in place a transparent policy for rationalisation of staff and undertaken a
cadre review of nursing

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 25.00 Crores Rs. 30.84 Crores
Release
Rs. 11.42 Crores Rs. 21.72 Crores
(till Sept 06)
Reported Expenditure Rs. 8.06 Crores Rs. 8.11 Crores
(till Sept 06)
Expenditure/ Release 70% 37%
Expenditure/ Allocation 32% 26%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Delivery Huts to be
evaluated
400 Delivery Huts established for
24 hr services, with referral for
high risk cases; 16685 deliveries
and 1690 referrals

7000 ASHAs, 986 ANMs, 200
SNs, 147 MOs, 23 Specialists
contracted, 127 specialists
empanelled.
In some villages, villagers have
pooled resources and hired 2
nd

and 3
rd
ANMs
Sakhi as link worker in urban
slums

EmOC services in 45 FRUs
24X7 facilities in 146 PHCs
Labour rooms and OTs renovated
in DHs and SDHs
Under Janani Suraksha Yojana,
cash benefit to 15555 pregnant
women to the amount of Rs.88.47
lakhs disbursed

Doing social audit / verbal autopsy
for maternal deaths, involving the
community


- 129 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
CHILD HEALTH
Newborn care corners established
in DH & SD Hospitals - all required
equipments supplied to DHs and
SDHs
All CHCs equipped with referral
ambulances
IMNCI Strategies implemented in
5 districts.
Supply of AD syringes ensured
and 100% in use.
School Health - Health card
issued to all school going children;
De worming followed by iron
supplementation to combat
nutritional anaemia
Do baseline
haemoglobin
measurements before
deworming
Develop convergence
with Sarva Shiksha
Abhiyan, as under SSA
Rs. 1,200 is available
per child for school
health
FAMILY PLANNING
Daily sterilisation at DH and SDH
Regular camps at CHC level
Accreditation with PHP in Vikalp
Regular NSV camps with strong
planned IEC
MOs trained in NSV
Social Marketing condoms even
available at ration shops
Sterilisation should be
combined with strong
IEC on age at
marriage; spacing
methods; PNDT;
breastfeeding
GOVERNANCE














Speed up DPMU staff
recruitment and
subsequent training
Look at the Block level
PMUs being done in
Punjab
Mission Steering Group meeting
regularly
District Missions are active
Delegation of powers is being
used
All SKS and sub-centre joint
accounts opened
Training on accounts maintenance
upto PHC level
User fees are being retained and
utilised at SKS level
DHAP preparation underway in 9
districts with involvement of
VHSCs
SPMU and DPMU fully functional
and trained

Block PMU planned

TRAINING/ IEC/ NGO INVOLVEMENT
Do monitoring of SBA and
Anaesthesia trainings
Anaesthesia training 100% target
achieved for 06-07


- 130 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
SIHFW renovation under process
Training calendar in place
Training being outsourced
M&E
Computerisation up to CHC level.
Capacity building workshops of
Statistical wing and PO.
MIS formats introduced.
Computerised drug inventory, birth
& death registration, monitoring of
sex ratio at birth, and electronic
attendance of field staff
Strengthen monthly
meetings at PHC and
CHC levels
INNOVATIONS
Janani Suvidha Yojana (voucher
scheme for institutional deliveries),
collaboration with NGOs and pvt.
providers, referral linkages with
facilities for high risk cases
Vikalp Scheme (state-wide) for 8
lakh BPL households, for MCH
services through 113 PHPs

EQUITY AND ACCESS
Transparent placement policy for
rationalisation of staff
Nursing Policy - Cadre review and
HRD
One year of work in rural/ hardship
posting counted as two years of
work / recommended for post
graduation

OTHERS
Intra Communication regular
programme and financial review
(monthly & quarterly)
VHNDs being conducted regularly
and monitored
Health melas being conducted
regularly
Ensure that health
melas have full package
of services
Procurement policy revised; GMP
as per schedule followed
Further decentralisation
procurement power of civil
surgeons increased from Rs.
25,000 to Rs. 1 Lakh



- 131 -


Progress on 13 identified process indicators:

S. No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 91.35%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
a. 80%
b. Delegated
3 % of sampled state and district programme managers aware of
their responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
100%
5 % of district not having one month stock of
g. Measles vaccine
h. OCP
i. Gloves
0%
6 % of districts reporting quarterly financial performance in time ---
7 % of district plans with specific activities to reach vulnerable
communities
100%
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
100%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
100%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 17.3%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 62.6%
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
---
13 M & E Triangulation ---


- 132 -


RCH II: FINDINGS OF 3
rd
JRM

HIMACHAL PRADESH


Himachal Pradesh performs favourably on the goals for IMR and TFR. The IMR (SRS 2005)
of 49 is better than the national average of 58, and close to the 10th plan goal of 45 for the
year 2007. With a TFR at 1.9 (NFHS 3 2005-06), the state has already achieved the RCH II
goal of 2.1 for 2010. However, the pace of implementation of technical strategies could be
better. Programme management arrangements are not firmed up yet.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 7.50 Crores Rs. 10.62 Crores
Release
Rs. 5.00 Crores Rs. 6.18 Crores
(till Sept 06)
Reported Expenditure Rs. 3.21 Crores Rs. 4.49 Crores
(till Sept 06)
Expenditure/ Release 64% 73%
Expenditure/ Allocation 43% 42%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Focus on strategies and
resources required to
transform FRUs to IPHS
standards
Simultaneous action on
deployment of skilled
manpower, provision of
equipments and infrastructure
is required to operationalise
the FRUs
Kit E to Kit P have been
supplied to FRUs
Blood storage facilities
being provided in 6 FRUs
Walk in interviews
conducted; 3 Paediatricians
and 4 Gynaecologists
selected
35 specialist doctors have
been posted from state pool
in FRUs
70 MOs have been trained
in EmONC so far. 5 more
MOs undergoing training
6 MOs trained in
Anaesthesia skills so far.
Presently 7 more MOs
undergoing training
17 staff nurses trained in
SBA
Increase in institutional
deliveries recorded.
Ensure that EmOC and
SBA trainings follow
national guidelines
Assess the proportional
increase in institutional
deliveries as a result of
JSY
Recruitment of ASHA to be
completed on priority
Link trained ASHA to health
facilities
State and District ToTs for
ASHA completed.


- 133 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
Disseminate correct
information on JSY norms to
communities through
awareness programmes and
IEC
3137 JSY beneficiaries.
CHILD HEALTH
Provide requisition to GOI for
AD syringes and essential
equipments
IMNCI being implemented
in 5 districts
Modules have been printed
2 master trainers have
undergone training
Referral transport services
provided in all districts
Reorientation training in
neonatal care being
conducted in districts for
SNs, ANMs, and female
health supervisors
Immunisation performance
declining
Immunisation
performance needs to
be improved.
FAMILY PLANNING
16 MOs trained in NSV
5 NSV mega camps
organised in Chamba,
Kullu, and Mandi districts
10% of total sterilisation
operations are NSV
Community mobilisation on
use of family planning
methods is being organised
at block levels.
Propagate EC pills.
ARSH
Counselling centres
operational in FRUs and
CHCs providing services
on two fixed days
Counselling camps also
being organised
TOT of master trainers
being conducted

GOVERNANCE & FINANCE
Explore possibility of locating
staff from other states
RKS needs to take up issues
in hospital management
Ensure regular receipt of FMR
from districts
SPMU appointments are
under process
Accountants have been
appointed in each district
BMO has been designated
as nodal officer of Block
PMU. Appointment of
Accountant-cum-stores
SPMU allocation is high
and needs to be
reviewed.

- 134 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
managers for Block PMU
are under process
State and District societies
have been equipped with
computer hardware support
and e-connectivity
TRAINING/ IEC/ NGO INVOLVEMENT
Training camps need to be
started urgently before the
onset of severe winter
ISD training for 10 MOs
BCC coordinators
appointed in 9 districts and
trained
Working together with
Block Extension Educator
and MEIO
Conduct sector wide
meetings of PRIs,
ASHA, AWWs etc. for
IEC promotion
MNGOs working in all
districts. They are also
conducting Social Audit.

INNOVATIONS / PPP
PHPs engaged in 4 districts
for laparoscopic
sterilisation.
PPP cells set up at district
levels and guidelines
issued for identification of
private agencies / NGOs
through RKS
Indira Gandhi Balika
Suraksha Yojana: cash
incentive on adopting
terminal family planning
method after birth of girl
child

EQUITY AND ACCESS
Maintain disaggregated data
for vulnerable groups (migrant
workers, SC, ST, women) in
all districts
Training for dais/mid wives in
remote areas as a stopgap
measure. Eventually, the
focus is on deliveries by SBAs
Identify targeted interventions
to meet needs of tribal
population
Multi specialty camps being
organised in remote and
tribal areas by involving
PHPs

PNDT and Sex Ratio
203 institutions registered
116 surprise checks carried
out


- 135 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
12 institutions given written
warning
Incentive to panchayats for
improving sex ratio
M&E
Disseminate information on
new M&E system to districts
and blocks
Technical Assistance required
for monitoring, supervision
and software application
Networking at state, district
and block levels completed.
State specific software
incorporated into RCH
formats and feedback
system in place.
Training of data operators
completed

OTHERS
Multi pronged strategy
required for addressing
problem of manpower. Tie up
with existing resources
Plan for a nurses cadre in the
State to resolve the problem
of shortage of technical staff
7224 monthly VHN days
organised in 06-07
Ensure that monthly
VHN days are organised
regularly at all
Anganwadi Centres



- 136 -


RCH II: FINDINGS OF 3
rd
JRM

JAMMU & KASHMIR


Jammu and Kashmir performs favourably on the goals for IMR and TFR. The IMR (SRS
2005) of 50 is somewhat better than the national average of 58, and close to the 10th plan
goal of 45 for the year 2007. TFR at 2.4 (NFHS 3 2005-06) is again approaching to 10th
plan goal of 2.3 in 2007. The pace of implementation needs to be fast tracked, to
compensate for delay in start up of RCH II programme. The state needs to firm up its
programme management arrangements at state and district levels.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 12.00 Crores Rs. 15.34 Crores
Release
Rs. 6.05 Crores Rs. 6.77 Crores
(till Sept 06)
Reported Expenditure Rs. 2.74 Crores Rs. 1.12 Crores
(till Sept 06)
Expenditure/ Release 45% 17%
Expenditure/ Allocation 23% 7%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Priority planning required for
increasing overall pool of
technical staff through e.g.
multiskilling of doctors
Pool of Specialists is
inadequate; Specialists are
reluctant to serve in rural
areas when there is shortage
even in cities.
Multiskilling of doctors being
taken up soon
35 district level Trainers
trained in SBA in the month of
October 06 and Training at
Districts to start in Feb, 07
16 batches MOs and lab
technicians trained in blood
storage
30 MOs trained in safe
abortion services
5333 outreach sessions held
1050 dais trained
IST training for 80 MOs, 225
ANMs, and 10 SNs
1400 nutrition demonstrations
held to address maternal
anaemia
For anaesthesia training,
HoDs at medical colleges are
reluctant to issue certificates
Increase outreach
sessions for ANC and
PNC on fixed days that
are advertised, even
where there is no sub-
centre.
Pre-fabricated
structures may be used
for sub-centres.
Certificate language can
be specific and clearly
state the purpose for
which the skill training
will be used.
JSY do sample
checking and evaluation
of the scheme.
JSY money to be paid in
cash. Money to be
routed through RKS and
imprest money may be
kept with ASHA. Money
has to be paid at the
time of delivery to help
the beneficiary mitigate
the cost of delivery.

- 137 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
JSY 7534 beneficiaries.
Uptake low because concerns
over mis-utilisation. Money
paid to beneficiaries by
checque.
CHILD HEALTH
Clear operational strategy is
required to implement IMNCI
with outcome oriented
approach
State level Trainers in
Integrated Management of
Neonatal and Childhood
Illness (IMNCI) scheduled to
be trained in Maulana Azad
Medical College w.e.f. 19
th

February 07
Newborn care corners
provided in 35 CHCs and
PHCs.

FAMILY PLANNING
Enhance awareness on
unmet needs and sterilization
options through specific IEC
and BCC
Enhanced IEC/BCC activities
initiated and showing results
Unmet need for Spacing as
reported in NFHS - 2 was 7.4
has come down to 6.0 as
reported in NFHS 3
9801 female and 213 male
sterilisations conducted
21500 IUD insertions done
8 teams of Gynaecologist/
Surgeon, SN and OT assistant
trained in laparoscopy
75 ANMs trained in IUD
insertion
1 NSV camp held

GOVERNANCE
Ensure that SPMU and
DPMU are in place at the
earliest
Completion of DAP to be
done by Oct.
Selection Process for all
DPMU completed, all DPMU
be in place by 15
th
Feb.07.
Interviews for Selection of
SPMU scheduled for 5, 6 & 7
th

February & it will be in place
by Feb. end
District Societies have opened
joint bank accounts, meetings
of societies held and
implementation of programme
through societies taken off for
better performance of the
programme


- 138 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
FINANCIAL MANAGEMENT
Expedite fund utilization and
fund reporting
Fund utilization has improved
likely utilization by March
ending is targeted at 50%

TRAINING/ IEC/ NGO INVOLVEMENT
Involve NGOs in creating
awareness of RCH II activities
NGO partnership initiated in
two Districts (Rajouri &
Kathua) through selected
MNGOs

M&E
Introduce new M& E formats
at the district level. Continue
data collection as per earlier
system till new M& E system
is set up
Steps initiated for collection of
data on new MIES format
developed by GoI
Districts asked to report on
new format

EQUITY AND ACCESS
Training for dais/mid wives in
remote areas as a stopgap
measure. Eventually, the
focus is on deliveries by SBAs
Proposed numbers of ASHAs
to be selected in current year
has been increased to 9500
and is proposed to be
increased further to13000
during the next year so as to
cover hamlets/sparsely
populated remote areas
Training of Dais taken up.
Eventually, focus is on
deliveries by SBAs. Training in
six districts is being taken up
soon.
Doctors who have recently
completed post graduation
have been posted to rural
areas
79 integrated RCH camps held
in underserved areas
In border areas, mobile teams
formed in consultation with the
Army. Local girls being trained
to act as health volunteers.

OTHERS
Prepare training calendar
for ASHA. Emphasize
training of ASHA in home
based care
Activate health
infrastructures through
adequate staffing
Develop a nursing cadre,
upgrade nursing institutes
9338 ASHA have been hired
and 5093 Trained in Module I.
Training of Module II (book 2,
3, 4) has started. Training
Calendar District wise
prepared
Nursing cadre is proposed to
be strengthened as
recommended by the National
Activation of PNDT
authority to be taken up
on priority.
PNDT reports need to
be sent regularly from
both Jammu and
Kashmir regions.

- 139 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
Programme Coordination
Committee (NPPC) on NRHM
Flexipool by starting 18 month
course for Graduate Nurses as
Licentiate Nurse practitioners
Nursing institutes are being
strengthened under NRHM so
as to develop nursing cadre.
PNDT authority has been
created and rules formulated
Sex Ratio survey conducted
and report published
Facility surveys for all PHCs
and 28 CHCs done



- 140 -


RCH II: FINDINGS OF 3
rd
JRM

JHARKHAND


Jharkhand has tried to move ahead in RCH implementation despite various natural
drawbacks including inaccessible terrains, unavailability of manpower. The state has used
provisional methods such as catch up rounds, speedy recruitment, and training of Sahiyyas
through tribal councils. However, the state needs to consolidate the efforts and improve
reach of RCH services in all areas including MH, CH, FP, and ARSH. Family planning and
malnutrition in children need to be particularly focussed upon in the state.

Financial progress
(05-06) (06-07)
Allocation Rs. 42.00 Crores Rs. 49.09 Crores
Release Rs. 40.60 Crores
Rs. 14.48 Crores
(till Sept 30, 06)
Reported Expenditure Rs. 30.38 Crores
Rs. 6.71 Crores
(till Sept 30, 06)
Expenditure/ Release 75 % 46%
Expenditure/ Allocation 72% 14%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Focus on nutritional
interventions for women
and children



Provide part of JSY incentive
at ANC and conduct a study
to see whether women getting
JSY money, are in better
state of nutrition
District hospitals made
operational for 24X7 services
30% PHCs conducting min 10
deliveries per month
Audit for Maternal deaths and
neonatal deaths
Improved DDKs
Training on MTP being done
Referral transport
Operationalise facilities for
24X7 services
CHILD HEALTH
Nutrition and health days
being conducted in 125
blocks
Promoting exclusive
breastfeeding and
complementary feeding
Conduct and closely monitor
monthly health days.
Arrange to bring children at
monthly health days. Identify
grade 3, and 4 children and
provide for their treatment and
care at designated health
facilities. Train MOs in
treatment of such children

- 141 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
FAMILY PLANNING
Community mobilization
Holistic advocacy for birth
spacing through standard
days method
Social marketing of BS means
Promotion to NSV
Promotion to sterilization

Improve OCP availability
Closely focus on bringing
down TFR from 3.3
Unmet need very high, should
be brought down, CPR to be
improved, under 18 marriages
to be reduced.
GOVERNANCE
Fast track recruitment
of staff for vacant
positions and
subsequent training.
Only SAM in position. 50%
DPMU staff recruited and
trained
Prepare and maintain a panel
of names
Fill up SPMU, DPMU
vacancies by March 07.
Develop DAPs, and use these
for preparing state PIP
FINANCIAL MANAGEMENT
Financial audit reports
need to be submitted to
GOI in time
All districts submitted FMRs
for December 06 in time.

TRAINING/ IEC/ NGO INVOLVEMENT
Sensitise departmental
staff in BCC
Develop nursing cadre
in the state
Explore the option of
providing scooter loans
for ANMs

Provide quarterly report for
PNDT act enforcement
Use GOI guidelines for NGO
selection and sanction of
funds to NGOs
INNOVATIONS
Partner with private sector
industries/ mining companies
for providing quality RCH
services


- 142 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 80%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
100%
3 % of sampled state and district programme managers aware
of their responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
100%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
None
6 % of districts reporting quarterly financial performance in time 100%
7 % of district plans with specific activities to reach vulnerable
communities
100%
8 % of sampled outreach sessions where guidelines for AD
syringe use and safe disposal followed
100%
9 % of sampled FRUs following agreed IP and health care
waste disposal procedures

10 % of 24 hrs PHCs conducting minimum of 10 deliveries per
month
45%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services Nil
12 % of sampled health facilities offering RTI/ STI services as
per the agreed protocols
Total 17 Health
Facilities

13 M & E Triangulation

- 143 -


RCH II: FINDINGS OF 3
rd
JRM

KARNATAKA


Karnataka could perform much better. The IMR (SRS 2005) of 50 is lower than the national
average of 58 but far away from the national RCH II goal of less than 30. The states MMR is
228 (SRS 2001-03), which is below the national average of 301 but again far off from the
national RCH II goal of 100. While several strategies have been formulated for the northern
districts with relatively poor indicators, ground level impact is yet to be seen. The state
should try to have public private partnership to reduce the goal indicators for RCH II.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 63.00 Crores Rs. 88.37 Crores
Release
Rs. 28.80 Crores Rs. 0 Crores
(till Sept 30, 06)
Reported Expenditure
Rs. 13.02 Crores Rs. 9.73 Crores
(till Sept 30, 06)
Expenditure/ Release 45% ----
Expenditure/ Allocation 21% 11%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
State has procured
pregnancy detection kit,
SSD kits and ANM kits

State needs into enter
into PPP to reduce the
MMR
Need to revise the strategy
of paying honorarium only
to the night deliveries. TN
pays an honorarium for
each delivery.
Examine feasibility of the
28 medical colleges to
manage FRUs
Cash payment should be
done to ANM for JSY.
Monthly health days to be
implemented with full
range of quality services.

CHILD HEALTH
State has procured
neonatal kits
IMNCI in 3 districts, ToT
under progress


- 144 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
Neonatal resuscitation
kits in 399 PHCs and 54
CHCs
State needs into enter
into PPP to reduce the
IMR
FAMILY PLANNING
The target achieved (from
April to Nov. 2006) for
sterilization, IUD and CC
users in the state is
104%, 99% and 103%
respectively. There have
been 231NSVs
conducted in the same
timeframe. The overall
utilisation on family
planning is 32%.

State needs aggressive
IEC and enter into PPP to
reduce the TFR
GOVERNANCE
State health societies
should meet regularly
Immediately recruit 560
ANMs who have been
trained recently. Expedite
the recruitment process for
doctors and nurses
Need to develop innovative
strategy to retain staff
nurses in the state.
Need to re-look into the
amount paid (Rs. 1000) as
remote area allowance to
doctors and make
necessary changes. Look
into the incentive patterns
of the neighbouring states.

TRAINING/ IEC/ NGO INVOLVEMENT
30% of the overall
targeted trainings has
been conducted
successfully.

Immediately conclude the
field appraisal for 9
districts


- 145 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
EQUITY AND ACCESS
25 tribal ANMs working
under NGO

Explore whether
management of facility
level services could be
handed over to NGOs.

OTHERS
100% achievement over
target for awareness
program for school
dropouts adolescent.
100%- awareness
program for school
students
100% - awareness
program for college
students
Iron fortified salts given to
adolescent girls

22% of the targeted
health melas conducted
(6 out of 22)
Try to conduct all the
targeted health melas by
31
st
March 2007.


- 146 -


RCH II: FINDINGS OF 3
rd
JRM

KERALA

Kerala is one of the best performing states of India in terms of IMR, MMR and TFR. The
state has the highest literacy rate as well as very good health seeking behaviour. However,
this has led to low utilisation of sub centers and the primary health centers, as people desire
and can afford better health facilities in the private sector. Kerala needs to focus on providing
high quality health services at sub center and PHC levels to meet the expectation of the
community. Kerala should now change gears and start implementing the proposed
strategies.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 38.00 Crores Rs. 49.61 Crores
Release
Rs. 21.44 Crores Rs. 17.70 Crores
(till Sept 30, 06)
Reported Expenditure
Rs. 2.64 Crores Rs. 3.03 Crores
(till Sept 30, 06)
Expenditure/ Release 12% 17%
Expenditure/ Allocation 7% 6%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Guidelines for JSY issued
JSY amount for each
PHC kept in joint account
of president, panchayat
and MO
Need more funds under
JSY
State may reallocate
unutilised funds from
other heads to JSY after
taking the consent of
GoI
Kerala can appoint ASHA in
tribal areas and link workers
in urban and non-tribal rural
areas.
State may submit a detailed
action plan for ASHA & link
workers to GoI

A committee has been
constituted for selection
of ASH in tribal areas
In remaining districts link
volunteers being
identified.

CHILD HEALTH
Initiatives have been
taken to strengthen
routine immunization


- 147 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
GOVERNANCE
Need to expedite the
process and fill up the
SPMU and DPMUs posts as
soon as possible
DPM in only one district
SPMU-100% staff
DPMU-33% staff
Need to expedite the
process and fill up the
DPMUs posts as soon
as possible
Make sure that all the
hospital development
society (HDS) of public
health institutions are
registered within the
mentioned time line
(October 30, 2006
Orders for hospital
development committee
issued

Need to regularize SC and
PHCs, improve standards
and quality of services
provided.
PHCs must be strengthened
for future requirements of
public health system
Need to rationalize the
staffing of specialists.
Vacant posts of state need
to be looked in to
separately. RCH specialists
posts should be filled on a
priority basis as per RCH II
guidelines.
404 MOs recruited and
posted to ensure 24hrs
services in CHCs and
selected PHCs
30 specialists recruited
and posted in CHCs
Make all the SCs
functional.
Try to strengthen and
increase the utilisation of
public health
infrastructure.
Need to revisit the idea of
not filling up ANM positions.
ANM positions may be filled
for future public health
system
ANM in all the SCs


TRAINING/ IEC/ NGO INVOLVEMENT
Capacity building been
done at each level.

MNGOs must be called for
periodic reviews
MNGO functional in 10
districts

For IEC- periodical
message on print and
electronic media,
message through diaries,
message on NRHM to all
the PRIs

INNOVATIONS
First state in India
working towards e
banking facility


- 148 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
EQUITY AND ACCESS
Need to look into referral
protocols and revisit the
whole referral system. May
take the help of PRI
Received funds for
procuring 1 MMU

OTHERS
Procurement and
distribution of drugs and
equipment through
external agency
10 health melas
conducted




Try to conduct all the
targeted health melas by
31
st
March 2007.


- 149 -


RCH II: FINDINGS OF 3
rd
JRM

MADHYA PRADESH


State has done well to establish programme management arrangements, strengthen
institutions and go ahead with a number of innovative activities for improving RCH
implementation. The innovative activities need to be evaluated and upscaled, as well as
basic certain basic activities including strengthening of SHCs, better utilisation of ASHAs,
conduct of health melas, urban RCH for slum areas need to be speeded up.

Financial progress
(05-06) (06-07)
Allocation Rs. 93.50 Crores Rs. 121.86 crores
Release Rs. 66.20 Crores
Rs. 50.24 crores
(till Sept 06)
Reported Expenditure Rs. 25.24 Crores
Rs. 22.98 Crores
(till Sept 06)
Expenditure/ Release 38 % 46 %
Expenditure/ Allocation 27% 19%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
JSY component of
institutional deliveries to be
reported.

6.57 lakh inst. deliveries
during April-Dec 2006. JSY
beneficiaries are 2.25 lakhs

Procurement and
distribution of ASHA kits to
be speeded up
62% ASHAs selected. 46%
of selected ASHAs trained
in first module. TOT for 2nd
and 3rd module planned in
Feb-March 2007
Ensure payment for ASHAs
on time. Connect them to a
functional institution
Provide ID cards to ASHAs
Conduct health melas. Use
these for service delivery as
well as IEC/IPC about RCH
in the state
CHILD HEALTH
Bal Shakti Yojana for
malnourished children and
defaulter tracking for
children missed out in
regular immunisation
sessions in progress
Explore possibility of
covering children under
Vijaya Raje Janani Kalyan
Bima Yojana

GOVERNANCE
Recruitment process for
programme management
staff to be monitored
closely / fast tracked.
3 SPMU staff and 85%
DPMUs in place.
Maintain a panel of names
for further recruitments

- 150 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
Need for adequate
delegation of administrative
and financial powers at
district, sub district levels
including ANMs for
utilisation of untied funds at
SHCs
BMOs notified as Class I
officers, having drawing and
disbursing powers.
Sub centre/ upgradation of
CHCs to IPHS funds to be
utilised.
All new constructions/
institutions to be eco
friendly. Provide adequate
toilets, waiting enclosures,
etc.

TRAINING/ IEC/ NGO INVOLVEMENT
Training should be
coordinated with other
activities. Place trained
manpower in facilities,
where their skills can be
utilised.
Fast track establishment of
SIHFW in the state.
Provide quality MTP
facilities at government
institutions. Make people
aware of this through IEC.
MTP training for 50 MOs in
progress, 40 trained. MVA
training for 50 MOs in
progress 26 trained

IEC messages should
focus on the root cause of
poor health seeking
behaviour. Address socio
cultural problems such as
child marriages.

Build a nursing cadre in the
state
Swawalamban scheme
initiated for sponsoring
SC/ST girls for nursing
courses and having them to
execute bond for serving
govt. after graduation
Tie up with open school for
training 10th pass ASHAs
as ANMs
INNOVATIONS
Need to evaluate 24 hr
referral scheme/ other pilot
schemes before scaling up.
24 hr referral scheme
(Janani express) to be
scaled up to all districts
Good practices of the state
to be compiled and
published periodically in
form of newsletter, etc.
Identify CHCs/PHCs being
used by large number of
people. Use intersectoral
convergence for building
roads, water and sanitation
facilities, etc. at these
institutions

M&E AND TA REQUIREMENTS
State to develop system for
collection of data from
Web enabled HMIS system
for physical and financial
Monitoring reports sent by
Regional directors to be

- 151 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
SHCs/ PHCs at monthly
meetings. Feed data into
computer at PHCs/CHCs
and report electronically at
next levels.
progress developed.
Training of district staff well
underway
Concurrent audit started in
districts
made use of for closer
monitoring.
Donor partners to support
states in developing HMIS.
Develop current baseline,
and compile yearly
outcome data
Use ASHAs for collecting
data on key indicators
including IMR, MMR.
Immunisation in urban slum
areas to be monitored
separately and
disaggregated data to be
reported
Focus on urban RCH for
slum areas
OTHER ISSUES
Some key
recommendations of Goa
conference to be actioned
such as:
Maintenance of panel for
recruitment
Timely confirmation, salary
of contract staff
Integrate regular and
contract staff
Design career progression
for DPMU staff
CMHO to have power to
sign cheques for
expenditure approved by
District Health Society
HR consultant recruited for
addressing HRD needs of
SPMU/DPMU staff



- 152 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 84.34%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
3 % of sampled state and district programme managers aware of
their responsibilities
67%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
100%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
0%
8%
6 % of districts reporting quarterly financial performance in time Till 5th - 27%
Till 10th -70%
Till 15th 3%
(Not Having
100% District
Accounts
Manager)
7 % of district plans with specific activities to reach vulnerable
communities
100%
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
AD sy. Supply-
100%
Safe disposal-
23%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
44%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 67%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 13.04%
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
80%
13 M & E Triangulation


- 153 -


Joint Review Mission - RCH-II Madhya Pradesh

Field visit report, January 14-19, 2007

A Joint Review Mission led by Ministry of Health and Family Welfare, Government of India
and development partners visited the state of Madhya Pradesh to review the implementation
of the RCH II programme.

The Mission members included the following:

Ministry of Health and Family Welfare, Government of India
1. Mr. PK Agarwal, Director Finance Team leader
2. Dr. Manisha Malhotra, Assistant Commissioner Maternal Health

Department of Health & Family Welfare, Government of Gujarat
3. Mr. Amarjeet Singh, Principal Secretary DoHFW, GoG

Department of Public Health & Family Welfare, Government of Madhya Pradesh
4. Dr. AN Mittal, Jt Director Health Services
5. Dr. Jayashree Chandra, Jt. Director Maternal Health
6. Dr. DK Mangal, UNFPA representative
7. Dr. GC Sachdeva, ECTA representative

DFID
8. Mr. Billy Stewart, Health and AIDS Adviser
9. Dr. Jenny Amery, Senior Regional Health Adviser for Asia
10. Dr. Sushila Zetylin, Senior Social Development Adviser

GTZ
11. Dr. KB Singh, Health Adviser, Health Sector Support

UNFPA
12. Mr. Venkatesh Srinivasan, Assistant representative

PMSG, DC Division MOHFW, GOI
13. Pranav Priyadarshi, Consultant

On January 15, 2007, a briefing meeting chaired by Dr. Rajesh Rajora, Commissioner
Health GoMP was conducted. Progress of the state on RCH II was presented to the JRM
team followed by discussions on progress factors and key bottlenecks faced by the state.

Districts for field visits were decided in consultation with the Directorate officials and it was
sought to include one good performing district, and one poor performing district on RCH,
being Dewas and Raisen districts respectively. Health facilities covered in these districts is
as follows:

Dewas District hospital Dewas, CHC Bagli, CHC Sonkatch, PHC Bhouransa, SHC
Chapda
Raisen District hospital Raisen, CHC Bareli, PHC Sanchi, PHC Salamatpur, SHC
Sarakia, SHC sadalatpur

A debriefing session chaired by Mr. MM Upadhyaya Principal Secretary DoHFW, GoMP, and
attended by Dr. R Rajoura Commissioner Health DoHFW, GoMP, Dr. YR Sharma Director

- 154 -


FW, GoMP, other key functionaries of GoMP and JRM team members was conducted on
January 19, 2007. Observations of the field visits including key areas for improvement were
presented by the JRM team.

The JRM team is thankful to the officials of GoMP for extending utmost cooperation during
the conduct of the mission.

PROGRESS ON RCH PROCESS AND INTERMEDIATE INDICATORS

The states progress on RCH II process indicators has been satisfactory for 8 of the 13
proposed indicators (refer Annex 1). On indicators such as % of sampled state and district
managers aware of their responsibilities, % sampled outreach session where guidelines for
AD syringe use and safe disposal are followed, % sampled FRUs following agreed IP and
health care waste disposal procedures, % CHCs upgrades as FRUs offering 24 hr EmOC
services, the state has reported below satisfactory performance, while no data is provided
for M&E triangulation.

Under intermediate indicators (refer Annex 2) the state has performed well on upgrading
PHCs for 24X7 (98% of target), making 95% SHCs functional. However, only 10% of
targeted CHCs converted to FRUs, that too without blood storage facilities, and only 26%
FRUs/ CHCs, 24X7 PHCs offering RTI/STI services is a cause for concern. Training
generally has been quite slow in the state: for SBA only TOTs completed in 18 districts, only
4% ANMs trained in IUD insertion, only TOTs being completed for training MOs in life saving
anaesthesia skills, EmOC, and NSV.

SIGNIFICANT DEVELOPMENTS/ PROGRESS OVERVIEW SINCE LAST JRM

The state has done well on acting on most of the observations/ suggested actions of the 2
nd

JRM (observations and suggested actions vis-a-vis 2
nd
JRM is provided at annex 3), as well
as making progress in other areas of RCH II:

Positions of SPM, SFM, and 3 SDOs filled. SAM appointed.
10 other consultants in areas of HRD, NGO coordination, PNDT/legal, ARSH,
Gender, HMIS, etc. in position
47 DPMs, 38 DAMs and 37 DDAs in position
All 48 districts have formulated DHAP
District Health Societies constituted and actively monitoring RCH and other health
programmes in the districts
RKS formed upto PHC levels
(Some RKS using innovative ways of generating funds e.g. PHC Badi, in district
Raisen generated Rs. 68 lakhs through construction and leasing out of shops)

Financial and physical monitoring/reporting being strengthened, mainly through
development of software for physical and financial reporting, and training of staff in
using this.
Concurrent audit at districts being done. Rs. 33.11 crores refunded to GOI against
settlement of RCH I accounts
Directorate having 4 directors. One Director being specifically responsible for RCH II/
NRHM
BMOs upgraded to Senior Doctors and given drawing and disbursing powers
7 regional directors of the rank of joint ditercors, essentially responsible for
monitoring

- 155 -

External agency contracted for concurrent evaluation. Annual surveys for progress
on goals, and outcomes planned.
All MOs posted in periphery to get refresher training at district hospitals once in two
months
Impressive increase in institutional deliveries in the state.
(29% in 2004/5 to 74% in 2006/7 in Dewas, and 20.3% in 2004-05 to 42.35% in
2005-06 in Raisen. The state has progressed from 22 - 29.7% from NFHS 2 to 3)
JSY (68% utilisation by 2
nd
quarter 2006-07)
Innovative schemes for encouraging institutional deliveries and safe motherhood e.g.
Janani Express, Vijayraje Janani Kalyan Bima Yojana
Contractual staff at PHCs.
Close monitoring by District Collectors
Immunisation coverage in both districts visited was above state average (improved
from 22.6 % to 40.3% from NFHS 2-3)
o Dewas 56%
o Raisen 42.4%
Innovative scheme, called Bal Shakti scheme being carried out in the state in
coordination with DWCD, for identification and treatment of grade 3 and 4 children.
State support for training nurses from SC/ST communities in private nursing
institutions through state sponsored Swalamban scheme. Almost 550 candidates
availed of this during the first year of this scheme.

QUALITY OF STATE AND DISTRICT PIPs

The state has undergone three cycles of district planning, in 2004-05, 2005-06 and in 2006-
07. All districts have prepared integrated district action plans, including RCH II mainly
through DFID support. The district planning involved a fairly rigorous process of block and
district level consultations, which were presented at district level workshops for arriving at
district action plans. These plans were then appraised at state level meetings and activities
and required budgets were approved for all districts.

The detailed state RCH II PIP was prepared during 2005-06, including workplan and
proposed budget for a five-year period from 2005 to 2010, and subsequently in 2006 for the
year 2006-07. The state PIPs covered situation analysis, and strategies for various
programme areas including programme management, institutional arrangements and
technical areas of maternal health, child health, family planning, adolescent health, urban
RCH, and tribal RCH.


Internal consistency in the PIPs

The state has formulated quite comprehensive PIP, addressing all key areas of RCH II, with
workplan and budget allocation for these. However, there are some areas of concern:
Annual goals for intermediate indicators in line with the proposed goals needs to be
stated clearly.
The state has identified lack of manpower especially in terms of MOs/ specialist
MOs, and as a key constraint for RCH II in the state. However, strategy for facility
mapping and rationalisation of existing resources, and manpower have not been
addressed. There is also no mention of a comprehensive training plan in the PIP.
Situation analysis as well as indicators show the state to be poorly performing on
child health. However, budget allocation for child health has been reduced from
11.9% in 2005-06 to 0.7% in 2006-07.

- 156 -

In the 2006-07 PIP, the state has reported progress on proposed strategies in the
previous years PIP, but it would be desirable that the state should also identify key
problems in implementation of RCH II during 2005-06, and try to address these in the
2006-07, rather than merely continue with the original strategies, even if desired
progress was not made.

Monitoring system vis a vis the plan

The state is in the process of developing and implementing web enabled HMIS system by
integrating physical and financial progress. The Net based MIS is expected to be developed
in next three months. It is envisaged to use this for monitoring the progress of the districts on
day to day basis. It is also planned to integrate physical progress indicators with
disaggregated data. The web enabled MIS is planned to be implemented at block level once
all data entry operators are in position.

IMPLEMENTATION BOTTLENECKS

The states progress based on budget utilisation during 2005-06, and 2006-07 has been
quite tardy. During 2005-06 the reported utilisation was only 27% of allocation, while in first
half of 2006-07 it has been 19% of allocation. Some of the key bottlenecks as identified by
the state are:

Delay in approval of State RCH-II PIP (approved on 22
nd
July 05)
Vacant positions of RCH consultants
Placement of SPMU and DPMU staff delayed (completed in July 05). Positions at
districts level still vacant specially of DAM and DA
Staff took time to understand RCH and NRHM
Limited capacities on the development of concept note, ToR, QA, Monitoring and
Supervision
Delay in merger of different societies at State and District level
Delay in preparation & appraisal of Distt. RCH-II plans
Lack of availability of Private Sectors at district and sub district level
High vacancies of Specialists, MOs and ANMs
Less number of health institutions as per population norms

Key issues identified by the JRM team

Based on facility observations (checklist provided at Annex 4), discussions, and review of
reports, key issues and suggestions for further improvements for RCH II in the state are:

More focus required on neonatal and child health

- Neonatal care facilities (e.g. for keeping the newborn warm) were not present in
all places visited. Good neonatal care practices need to be emphasised, including
in non-IMNCI districts. This is a missed opportunity where districts are doing well
on deliveries.
- Alternate vaccine delivery needs to be emphasised by bringing it under RCH II
flexi pool funding.
- In Dewas, vaccines were collected by the ANM on Tuesdays and being stored in
private refrigerator till Friday.
- Emphasis on growth monitoring of children, and management of malnourished
children needs to be re-emphasised. Coordination between ICDS and health,
with ANMs also keeping track of malnourished children is required.
- Clarification of the content of post-natal visits.

- 157 -

In ASHA training, explore possibility of using NGOs for ensuring quality in the
training programmes. Select women carefully as ASHAs, and develop carrier plan
for those that are 10
th
passed, such as training them as ANMs.

Where private blood banks/blood storage facilities are present, these could be used
under PPP.

BCC/IEC need to be focussed on bringing transparency in implementation of
schemes, such as fees and charges to be paid by the patients and mechanisms for
monitoring and complaints addressal. Monitoring of JSY funds reaching actual
beneficiaries can be strengthened through taking a periodic random sample and
assessing as to whether the money actually was received by the intended
beneficiary. Increased IEC/BCC for Janani Express, JSY and Vijaya Raje Janani
Kalyan Bima Yojana could be made through explicit signage and hoardings,
messages on transport vehicles, through ASHAs, ANMs and AWWs, and Womens
self help groups.

Referral transport is still a major challenge to increasing institutional deliveries in
Raisen. The Janani Express scheme could be well documented and evaluated in
order to replicate in the entire state. Documentation could include the process of
establishing the scheme, challenges faced and how it can work in sparsely populated
areas.

Malaria prevention and treatment during pregnancy and for children could be
strengthened, e.g. clarification of policy for treatment of malaria among pregnant
women, hospitals to be equipped with bed nets, and nets provided through antenatal
visits in high prevalence areas.

Human resources issues need urgent attention. Mapping of human resources could
be conducted for better allocation of these in the state:
-


- There is a shortage of doctors, including both specialists for CEmONC facilities
(gynecologists, anaesthetists). Rationalise staff, involve private sector, and
conduct multiskilling of MBBS doctors in EmOC through FOGSI and in
anaesthesia, considering also incentives for trained MBBS doctors to stay in the
public sector. In the interim, vacancies for MOs could be filled up through ISM
doctors.
- The number of sanctioned ANM posts was low. Focus on posting of ANMs at
vacant SHCs, before placing 2 ANMs.
- Focus on SBA training. ANMs could also be provided hands on training at the
BEmONC and CEmONC centres where sufficient delivery load is there, since
many are not confident of conducting even normal deliveries.

Waste management needs to be improved, with segregation and proper disposal of
biomedical waste, as per GOI guidelines.

Supervision mechanisms from bottom to top, i.e. supervision SHCs by LHVs and
PHC staff; of PHCs and CHCs by district authorities and of the districts by the state
programme managers, needs to be revived. For this purpose, it is suggested that
appropriate checklists for each level and facility may be developed, and used during
the visits by concerned staff, so as to assure minimum services expected from them.
Job charts of different functionaries should also be displayed.

- 158 -

ANMs could be trained to be used as first point of contact at village level. All public
and private facilities in the district could be mapped, and the ANM could provide
required services, or refer cases to appropriate facilities depending on requirements.
Compliment this with innovative schemes such as janani express.

Develop public health cadre. BMOs and CMHOs should be chosen from the public
health cadre, and not being PGMOs/specialists, who could work in their area of
specialisation.

Simplified financial management. A district plan, once approved at the state level,
should not be subject to further delays. Capacity to utilise substantial funds released
to the district, especially at block level, needs to be strengthened.
o Sub-centre untied funds (20,000 Rs)
o Upgradation of CHC to IPHS (40 lakhs Rs)
o Annual maintenance grant for PHCs (50,000 Rs)
o Untied funds for PHC (25,000 Rs)

Overall, utilisation of the district is 32% in Dewas, and 19% in Raisen in nine months
during 2006-07, is very low.

Tribal plan and Urban health plans to be developed and implemented. Where mobile
medical clinics are being used, plansshould set out how these will deal with
emergencies.

There appeared to be limited data available on health and demographic indicators, or
on service gaps. Record systems were not able to link patient encounters to, for
example, show the care given over a whole pregnancy. The state has plans for
improving the data available on health through annual household surveys.

Renewed emphasis on all aspects of the family planning programme is needed,
including spacing methods. More could be done to improve access to emergency
contraception, where training has been provided for medical officers but not for other
workers. Since it is an OTC drug in India, it should be possible to include in the
ASHA kit, and there may be opportunities for social marketing approaches to
increase awareness of availability.

Strengthened provision of RTI and STI services is needed.


- 159 -


Annex 1
RCH II PROCESS INDICATORS
Sr.
No.
RCH
INDICATOR
Level of
achievement
Calculation of the indicator by the State& methodology of data
collection in JRM
% as on
31/12/06
Task to be performed in
JRM Review
1 % of ANM
positions filled
80% Source of Information: Programme Data/Financial Data on Salary
disbursement
Type: Secondary
Definition:
ANMs positions filled till date (1067+9017=10084) X 100
Number of vacant positions as on 1 April 2005 (9756+2200=11956)

Vacant is defined as regular vacancies against sanctioned plus
those approved for contractual appointments
84.34% Analysis of data presented
by the State
2 a. % of districts
having full-time
programme
manager for
RCH
b.
Administrative
and financial
powers
delegated
90% Source of Information:
FMIS (Release of salary in the previous month)
Data to be captured through secondary source. The indicator has
two parts to it. The first part can be captured through secondary
data while for the second part, the job functions of programme
managers and any other support documents related to
administrative and financial powers will have to be provided.
Type: Secondary:
This data can be compiled from the finance section through salary
disbursement (district-wise)
Definition:
Number of districts having full-time programme
managers in position as on date (48) X 100
Number of districts in the state(48)
100% A. Achieved.

B. Executive Body of State
Health Society has already
sub delegated Delegation
of Power to State & district
level state.


- 160 -


Sr.
No.
RCH
INDICATOR
Level of
achievement
Calculation of the indicator by the State& methodology of data
collection in JRM
% as on
31/12/06
Task to be performed in
JRM Review
3 % of sampled
state and district
program
managers
aware of their
responsibilities
80% Source of Information: Programme Data
Check out whether the state is capturing this information? If no, ask
state to use proxy variable and provide

Proxy:
Number of Program Managers underwent
induction/orientation programme (32) X 100
Number of Program Managers(48)
67% Depending on the scores,
the JRM can frame their
questions
(Orientations
programme/workshops on
awareness are held)
4 % of sampled
state and district
programme
managers
whose
performance
was reviewed
during the past
six months
60% Source of Information:
Programme Review Minutes
Number of programme reviews done in the last six months

Type: Secondary
Number of programme managers whose
performance was reviewed in the past six months(48) X 100
Number of programme managers(48)
100% If the state has not
conducted any programme
managers review, then
they have to be probed for
reasons?
-How have they then been
monitoring their
performance? How is the
info consolidated?
-Have they initiated any
steps in this direction? If
so, what all steps have
been initiated?
5 % of district not
having at least
one month
stock of
a. Measles
Vaccine
b. OCP
c. Gloves
<10% Source of Information: Stock Register/MIS

Type: Secondary
This information has to be compiled from stock registers maintained
at district level. Compile district-wise information for last six months
by opening balance, received, distributed and balance (month-wise)
a. 0%
b. 0%
c. 8%
Examine data on logistics
and discuss if any flaws are
observed. Find out the
logistics mechanism
(indenting, procurement,
disbursement etc) followed
by the state

- 161 -


Sr.
No.
RCH
INDICATOR
Level of
achievement
Calculation of the indicator by the State& methodology of data
collection in JRM
% as on
31/12/06
Task to be performed in
JRM Review
6


% of districts
reporting
quarterly
financial
performance in
time*
80% Source of Information: FMIS Collect for two quarters
Ask when districts were supposed to report and when reported.

Type: Secondary

Definition:
Number of districts reporting quarterly financial
statement on time (48) X 100
Total Number of districts(48)

A. Till 5
th
-
27%
B. Till 10
th

-70%
C. Till 15
th

3%

(Not
Having
100%
District
Accounts
Manger)
Analyze data by districts
and find out reasons for
delay (if any). Examine by
budget heads so that an
idea of major expenditure
can be gauged and
subsequently areas of
reviews and questions
could be framed for district
visits
7 % of district
plans with
specific
activities to
reach
vulnerable
communities
80% Source of Information:
State consolidated summary matrix of interventions by districts (if
available)
Type: Secondary:
State can be asked to look into PIPs and compile district-plan
activities in matrix form if not available.
Definition:
Number of districts with specific vulnerable plans X 100
Total Number of districts
Definition of Vulnerable community: SC, ST, BPL, not
accessible/remote areas planning etc.
100% Examine census
distribution of SC/ST
population and analyze
district vulnerable plans
against it. For BPL and
other indicators, find out
the rating from state and
undertake the review

- 162 -


Sr.
No.
RCH
INDICATOR
Level of
achievement
Calculation of the indicator by the State& methodology of data
collection in JRM
% as on
31/12/06
Task to be performed in
JRM Review
8 % of sampled
outreach
sessions where
guidelines for
AD syringe use
and safe
disposal
followed
80% Source of information:
Routine Immunization records
Type: Secondary
Definition:
Number of sampled outreach sessions where AD syringe
use and safe disposal guidelines are being followed X100
Number of sampled outreach sessions
AD sy.
Supply-
100%
Safe
disposal-
23%
AD syringe logistics in
terms of supply and
distribution can be verified
at district level and few
ANMs can be asked
related questions
9 % of sampled
FRUs following
agreed IP and
health care
waste disposal
procedures

80% Source of information:
-Correspondences between state and district and district and FRUs
on IP and waste disposal protocols
-Training related to the above
-IP supplies during the year at district etc.
Type: Secondary
If this activity has been initiated, then check with the state of what
all activities have been done in this regard and whether any sample
check has been undertaken. If yes, then ask the state to provide
information by using the following definition
Definition:
Number of sampled FRUs following agreed IP and
waste disposal protocols (75) X100
Number of sampled FRUs 170
44% (MIS doesnt capture this
information)
10 % of 24 hrs
PHCs
conducting
minimum of 10
deliveries per
month
50% Source of information: MIS
Type: Secondary
Definition:
No. of 24 hr PHCs conducting 10 deliveries/month 211 X 100
Total Number of 24 PHCs in the state (314)
67% Examine institutional
delivery trends of 24hr
facility by districts and find
out districts that are
performing well and
otherwise. Explore reasons
& steps initiated to increase
uptake

- 163 -


Sr.
No.
RCH
INDICATOR
Level of
achievement
Calculation of the indicator by the State& methodology of data
collection in JRM
% as on
31/12/06
Task to be performed in
JRM Review
11


% of CHCs
upgraded as
FRUs offering
24 hr EmOC
services
50% Source of information:
MIS/Programme

Type: Secondary

Definition:
Number of CHCs functioning as FRUs (6) X 100
Total number of CHCs proposed during the year

Compile information for 6 months by districts(46)
13.04% Check whether progress is
according to work plan or
not
12 % of sampled
health facilities
offering RTI/STI
services as per
the agreed
protocols
60% Source of information: MIS (partial)-Proxy

Type: Secondary

Number of facilities providing RTI/STI services by districts could be
compiled
Number of facilities where lab-tech is posted and available
Number of lab-tech who have undergone RTI/STI training
All facilities where lab-tech has undergone training or having VCTC
can be considered as Numerator

Definition:
Number of health facilities providing RTI/STI services
as per protocols X 100
Number of health facilities
80%
13 M&E
Triangulation

* State is having its own MIS for monthly physical & financial reporting of RCH-II programme activities

- 164 -


Annex 2
INTERMEDIATE INDICATORS

Name of State: Madhya Pradesh

Reporting period: October December 2006

S.
No.
Indicator Target as
per PIP
(06-07)
Achievement Remarks Source
of data
Infrastructure
1. No. of PHCs upgraded to
provide 24X7 services
1
214 211
No. of health facilities upgraded to FRUs, fulfilling the minimal criteria as per the FRU
guidelines (at least the 3 critical criteria)
a. District Hospitals
1
46 35
b. Sub-Divisional Hospitals
1
32 11
c. CHCs
1
92 10
(blood storage
facilities is
lacking even
then performing
LSCS

2.
d. Others (pl. specify)
1
-
3. % of functional Sub-Centres
(ANM is available and
working out of the facility)
8835 95.57% (8453
is functional
with ANM)


4.
Total Number of FRUs,
CHCs and 24 hr PHCs
offering RTI/STI services
1

170 26.4%(45
facilities)
with support of
NACO

Staffing
5.
% of ANM positions filled
2
2200 48.5% contractual
under RCH

Programme Management
6.
SPMU in place with 100 %
staff
4 75 %
7.
% DPMU staff in place
3
48 77.77%
Training
No. of personnel trained in IMNCI
MOs
1
144 54.1% (78)

8.
ANMs
1
144 283 achievement is


- 165 -


S.
No.
Indicator Target as
per PIP
(06-07)
Achievement Remarks Source
of data
AWW
1
144 1353
cumulative
since 2005 also
include 2
UNICEF
supported
districts
also

Supervisors 114

No. of personnel trained in SBA
MOs
1
-

ANMs
1
36

9.
Staff nurse
1

100
14
(TOT
completed in 18
districts)

No. of personnel trained in IUD insertion
MOs
1
-
Not included in
PIP

ANMs
1
3840 187

10.
Staff nurse
1
- Not included in
PIP

No. of MOs trained in
Life-saving anaesthesia
skills
1

16 -
Tot held
EMOC
1
16 5 13 master
trainer trained
batch of 8 MOs
to be started at
Indore from
22
nd
Jan. 07

11.
NSV
1
100 - training is under
process during
NSV Mega
camps being
held in different
districts

Maternal Health
12.
Proportion of ANC
registrations in first trimester
of pregnancy
1497051 45.7%

13.
Proportion of registered
pregnant women who
received at least 3 ANC
checks
1497051 76.46%


- 166 -


S.
No.
Indicator Target as
per PIP
(06-07)
Achievement Remarks Source
of data
14.
Proportion of registered
pregnant women who
received TT2 or booster
1497051 92.92%

15.
Proportion of registered
pregnant women who
received 100 doses of IFA
tablets / syrup
1333985 89.1%

16.
Proportion of C-section
births at FRUs
123960 6.42%
17.
Proportion of Mothers and
newborn visited as within 2
days of home delivery by a
trained community level
health provider/AWW or
health staff (ANM/Nurse
/Doctor)


System of reporting is being developed.


18.
Proportion of JSY
beneficiaries who availed
services in the quarter out of
total identified beneficiaries
335000 67.36%
19.
% of planned RCH outreach
sessions held (RCH+DFID)
613 55.13%
Child Health
20.
% of planned Immunization
sessions held
918840 Formats have
been sent data
not received
from districts

21.
Proportion of children 12-23
months who are fully
immunised
4
1997519 67.1%
Family Planning
22.
Male Sterilisation
Acceptance Rate
5
40000 14.2 % (5685)

23.
Female Sterilisation
Acceptance Rate
5
542942 41% (222583)

24.
IUD Acceptance Rate
6
663095

49.23%
(326500)


Adolescent Health
25.
Proportion of ANC
registrations in first trimester
of pregnancy for women <
19 years of age

26.
Proportion of registered
pregnant women < 19 years
of age who received at least
3 ANC checks



System of Reporting is being developed




- 167 -


Annex 3

OBSERVATIONS AND SUGGESTED ACTIONS VIS A VIS FINDINGS OF 2
ND
JRM

Financial progress (05-06 and till 3
rd
quarter of 2006-07)

FY 2005-06 (Rs. Crores)
April 1, 2006 to December
31, 2006 (Rs. Crores)
Allocation (NPCC) 93.50 121.86
Release 66.20 84.53
Expenditure 25.30 42.90
Expenditure/ Release 38 % 50%
Expenditure/ Allocation 27% 35%

Rs. 33.11 crores refunded to GOI towards settlement of RCH I accounts

Component wise observations and suggested action points:

Achievements/
Observations
Recommendations of 2
nd
JRM Suggested action (if any)
GOVERNANCE
Full time Mission Director
for NRHM in place.
SPMU/DPMU staff largely
recruited and trained.
However, there are still a
number of vacancies. An
advertisement has been
recently released.


Recruitment process to be
monitored closely / fast
tracked

(Recruitments largely carried
out)
Orientation/induction training
of new incumbents required
to make them aware of job
requirements
In case of drop outs, offers
from reserve panel to be
issued so as to fill up all
vacant posts. Post of state
accounts manager needs to
be filled, as state finance
manager is overburdened.
Pay package of consultants
needs to be re looked/
enhanced so that
experienced and better-
qualified people join.
Formulated guidelines for
delegation of
administrative and
financial powers at the
state.


Need for adequate delegation
of administrative and financial
powers at district, sub district
levels including ANMs for
utilisation of untied funds at
SHCs

(Sub center/ upgradation of
CHCs to IPHS funds are lying
unutilised)
Process of upgradation of
CHCs to IPHS needs to be
expedited.
For utilisation of SHC untied
funds, PRI department
needs to be involved and a
joint strategy for this worked
out
TECHNICAL INTERVENTIONS
Institutional deliveries
improved from 26% to
40.58%

JSY component of institutional
deliveries to be reported.

(6.57 lakh inst. deliveries
Based on Unicef study for
institutional deliveries in the
state: key areas of concern
including low ANC, low

- 168 -


Achievements/
Observations
Recommendations of 2
nd
JRM Suggested action (if any)
during April-Dec 2006. JSY
beneficiaries are 2.25 lakhs)
awareness about inst.
delivery schemes,
unavailability of transport in
most cases needs to be
addressed.
44% ASHAs selected.
40% of selected ASHAs
trained in 1st module.
TOT for 2nd and 3rd
modules completed.
Procurement of ASHA kits
under progress
Procurement and distribution
of ASHA kits to be speeded up

(62% ASHAs selected. 46%
of selected ASHAs trained in
first module. TOT for 2
nd
and
3
rd
module planned in Feb-
March 2007)
Distribution of ASHA kits
expected by 31 Jan 2007.
Provision of supplies at
regular intervals for these
kits would also need to be
addressed.
Recruitment of contract
staff, training and
provision of equipments
for operationalising
BemOC/CemOC in
progress


Training should be coordinated
with other activities. Place
trained manpower in facilities,
where their skills can be
utilised.

(56/170 CEmOC made
functional. 305/500 BemOC
made functional)
Blood storage/linkage with
blood banks at district level/
other needs to be ensured
Training of MOs in EmOC
and anaesthetic skills needs
to be scaled up.
Telephones functional at
BemOC/CemOC. Repair/
renovation of OTs, labour
rooms at CHCs/ BemOCs
in progress.
All new constructions/
institutions to be eco friendly.
Provide adequate toilets,
waiting enclosures, etc.

Build a nursing cadre in the
state

(Swalamban scheme for
sponsoring SC/ST candidates
in private institutions, and
obtaining a bond from them to
serve in Governemnt sector
for 5 years is a good initiative)

TRAINING AND NGO INVOLVEMENT
MTP training for MOs in
progress


Provide quality MTP facilities
at government institutions.
Make people aware of this
through IEC.

(MTP training for 50 MOs in
progress, 40 trained. MVA
training for 50 MOs in
progress 26 trained)
11 tribal districts mobile
medical units already
functioning. 19 additional
mobile units proposed could
be provided emergency
contraception pills
State has conducted TOT for
MVA training and entered
into long term aggreeemet
with IPAS for trainings. This
needs to be speeded up for
ensuring MTP services at
24x7 PHCs

- 169 -


Achievements/
Observations
Recommendations of 2
nd
JRM Suggested action (if any)
IEC messages should focus
on the root cause of poor
health seeking behaviour.
Address socio cultural
problems such as child
marriages.


INNOVATIONS
Provision of 24 hr referral
transport, with telephone
connectivity and mapping
of pregnant women being
piloted in 3 districts
Need to evaluate this and
other pilot schemes before
scaling up.
Proposal for scaling it in all
districts. However,
evaluation of this could be
considered before upscaling.
50 blocks being
developed as model
blocks with all essential
health care facilities

(Reported doubling of
institutional deliveries in
1 year period in these
blocks. SC/ST and other
disaggregated data of
usage being obtained)
Identify CHCs/PHCs being
used by large number of
people. Use intersectoral
convergence for building
roads, water and sanitation
facilities, etc. at these
institutions


M&E AND TA REQUIREMENT
GOI MIES formats being
adopted
Financial monitoring and
reporting software
developed. Training for
PMUs planned
Data triangulation and
validation planned

(2 days workshop being
organised during 15-16
january 2007, for
improving health
statistics in the state)
State to develop system for
collection of data from SHCs/
PHCs at monthly meetings.
Feed data into computer at
PHCs/CHCs and report
electronically at next levels.
Donor partners to support
states in developing HMIS.
Develop current baseline, and
compile yearly outcome data.
Use ASHAs for collecting data
on key indicators including
IMR, MMR.
Incorporate monitoring of
outcomes in the web based
HMIS
Immunisation in urban slum
areas to be monitored
separately and disaggregated
data to be reported.
Urban plans to be fast
tracked
OTHER ISSUES
Some key recommendations
of Goa conference to be
actioned:
- Maintainance of panel for
recruitment
- Timely confirmation,
HRD aspects need to be
addressed on priority

- 170 -


Achievements/
Observations
Recommendations of 2
nd
JRM Suggested action (if any)
salary of contract staff
- Integrate regular and
contract staff
- Design career
progression for DPMU
staff
- CMHO to have power to
sign cheques for
expenditure approved by
District Health Society


- 171 -


Annex 4
FACILITY OBSERVATION CHECKLISTS
Facility Observation Checklist - District Raisen (Madhya Pradesh)
Parameters
SHC
Sadalatpur
(17/1/07)
District
Hospital
Raisen
(17/1/07)
PHC
Sanchi
(BEmOC)
(17/1/07)
PHC
Salamatpur
(17/1/07)
SHC
Sarakia
(18/1/07)
CHC
Bareli
(Designate
d CEmOC)
(18/1/06)
Service Provision
- Routine Delivery Services
(24hrs) N Y Y N N Y
- Manage Obs. Complications N Y N N N Y
- Female Sterlisation Services N
Only in
camps N N N
Only in
camps
- NSV Services N
Only in
camps N N N
Only in
camps
- MTP N Y N N N N
Staff Availability
- Ob/Gyn or trained M.O N Y N N N Y
- Anaesthesiologist N Y N N N N
- Staff Nurses/ANM's (atleast
4) 1 Y 2 2 N Y
- Lab Technicians N Y Y Y N Y
Equipment and Supplies
- NSV Kit N N N N N N
- Gluteraldehyde Solution N Y N N N Y
- RPR Test Kits N N N N N N
- Injection Magnesium
Sulphate N N N N N N
- Doxycycline N Y Y Y N Y
- Functioning BP Instrument Y Y Y Y Y Y
- Measles Vaccine N Y Y Y N Y
Facility Infrastructure
- Needs assessment done N Y N N N Y
- Plans for Bio-waste disposal N N N N N N
- Visual Privacy in Labor
Room N Y Y N N N
- Visual Privacy in OPD N Y Y Y N Y
- Back-up power facility N Y N N N Y
Referral Services
- Ambulance availabilty N Y Y N N Y
Client Convenience
- Covered waiting area Y Y Y Y Y Y
- Toilets (separate, clean and
functional) N Y Y Y Y Y
- Signage to guide client N Y Y Y N Y
- Signage on rooms N Y Y Y N Y
Record Review
Average number of monthly
institutional deliveries in the
last quarter 0 350 NA 0 0 100


- 172 -



Facility Observation Checklist - District Dewas (Madhya Pradesh)
Parameters
CHC
Sonkatch
(17/1/07)
PHC
Bhouransa
(17/1/07)
CHC Bagli
(18/1/07)
SHC
Chapda
(18/1/07)
District
hospital
(18/1/07)
Service Provision
- Routine Delivery Services
(24hrs) Y Y Y N Y
- Manage Obs. Complications N Y N N Y
- Female Sterlisation Services
Only in
camps N Periodic N Y
- NSV Services Regular
Only in
camps Periodic N Y
- MTP N N Periodic N Y
Staff Availability
- Ob/Gyn or trained M.O N Y Y N Y
- Anaesthesiologist N N N N Y
- Staff Nurses/ANM's (atleast
4) Y 2 2 1 Y
- Lab Technicians Y Y Y N Y
Equipment and Supplies
- NSV Kit Y N Y N Y
- Gluteraldehyde Solution Y N N N Y
- RPR Test Kits Y N N N Y
- Injection Magnesium
Sulphate N Y Y N Y
- Doxycycline Y Y N N Y
- Functioning BP Instrument N Y Y Y Y
- Measles Vaccine Y Y Y N Y
Facility Infrastructure
- Needs assessment done Y Y Y Y Y**
- Plans for Bio-waste disposal N N N N Y
- Visual Privacy in Labor
Room Y Y Y N Y
- Visual Privacy in OPD Y Y Y Y Y
- Back-up power facility Y Y Y N Y
Referral Services
- Ambulance availabilty Y N* Y N Y
Client Convenience
- Covered waiting area Y Y Y Y Y
- Toilets (separate,clean and
functional) Y Y Y Y Y
- Signage to guide client Y Y Y Y Y
- Signage on rooms Y Y Y Y Y
Record Review
Average number of monthly
instituional deliveries in the last
quarter 150 44 83 0 1000

* Facility has referral arrangement under Janani Express
** Being a 300 bedded hospital, it may be converted into a medical college

- 173 -


RCH II: FINDINGS OF 3
rd
JRM

MAHARASHTRA


Maharashtra performance could be much better. The IMR of 36/38 (SRS 2005/ NFHS3:
2005-06) is considerably lower than the national average of 58, but nowhere close to the
best performing states. The states MMR is 149 (SRS 2001-03) is well below the national
average of 301. TFR at 2.1 (NFHS 3, 2005-06) is at par with the national RCH II goal of 2.1
by 2010. However, a major challenge for the state is to tackle child marriage (40%). In
addition there is a shortage of skilled manpower in the state. Financial utilisation has been
very low. The state needs to fast track implementation.

Financial progress
(05-06) (06-07)
Allocation Rs. 115.50 Crores Rs. 157.22 Crores
Release
Rs. 52.80 Crores Rs. 78.75 Crores
(till Sept 30, 06)
Reported Expenditure
Rs. 15.98 Crores Rs. 5.55 Crores
(till Sept 30, 06)
Expenditure/ Release 30% 7%
Expenditure/ Allocation 14% 4%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
287 accredited private
institutions for JSY
All the ANMs to be recruited
by the end of February 2007.


Train doctors with multi
tasking including SBA and
anesthesia.
Identify medical colleges
for organising training
programmes.
Need to rationalize
staffing
Need to reorient all the
CMOs on various RCH II
components including
JSY
Anesthetists have been
redeployment to FRUs
Action plan may be
prepared for SBA
training/ EmOC
training
Try to nominate the pada
workers as per the
guidelines of ASHA
Educational qualification
of pada workers may be
relaxed.
Community based new
born care may be given
32 ANMTCs fully functional

- 174 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
by already existing Arogya
Sakhi in tribal area
(provide ASHA training to
AS)
Village level referral plans
made and displayed at
strategic locations

Services of safe abortion
expanded by involving private
doctors
MVA technique piloted and
expanded in 10 districts along
with logistic support with the
help of Ipas

JSY has been successful in
the state
Need more funds under JSY
State may reallocate
unutilised funds from
other heads to JSY
after taking the
consent of GoI
40% of the girls in the
state are getting
married under 18
years; this is a matter
of concern, and need
to be taken up more
seriously.
State needs to work
towards reducing
anaemia level of
pregnant women
CHILD HEALTH
Neonatal resuscitation kits
procured
IMNCI and newborn care
training in 9 districts including
5 tribal
Paediatric care at all FRUs
Print and supply of modified
growth records with inbuilt
immunization record and IEC

Try to hire vaccinator
Ensure proper fund flow
for immunization.
Ensure proper
maintenance of cold
chain.
Routine immunization
strengthened

FAMILY PLANNING
By March end orders would
be placed for procurement of
laparoscopes.


- 175 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
Need to concentrate more
on IEC of NSV
State needs to
promote IUD,
tubectomy and EC
GOVERNANCE
75 FRUs functional
Try to take onboard ex
MHSDP staff.
Try to sign bond with
DPMU staff to ensure
retention
Provide good working
environment to SPMU and
DPMU staff.
SPMU- all positions filled
except SDM
79% of the DPMUs in place

State needs to implement
RCH II in cantonment
areas by joining hands
with defense department.

TRAINING/ IEC/ NGO INVOLVEMENT
ToT completed in life saving
skills in anaesthesia from 6
medical college
Other major trainings
conducted and percent
achievement over target:
- BemOC: 81%
- SBA: 17%
- MTP: 63%
- LS anaesthesia: 117%
- Arogya sakhi: 59%
- IMNCI: 260%
- EmNC: 209%
- Tubectomy/Minilap:6%
- NSV: 48%

INNOVATIONS
Web based MIS in place
Developed standard
treatment protocol
Piloting quality assurance
initiative in Ahmednagar
district.
Piloted health insurance
scheme through CBOs

OTHERS
Selection of consulting
agency for procurement of
health care goods
Logbook to track trained
manpower.



- 176 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 72%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
3 % of sampled state and district programme managers aware
of their responsibilities
88%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months

5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
6 % of districts reporting quarterly financial performance in time 40%
7 % of district plans with specific activities to reach vulnerable
communities
100%
8 % of sampled outreach sessions where guidelines for AD
syringe use and safe disposal followed

9 % of sampled FRUs following agreed IP and health care
waste disposal procedures
90%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per
month
72%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services
33 %
12 % of sampled health facilities offering RTI/ STI services as
per the agreed protocols
18%
13 M & E Triangulation

- 177 -


RCH II: FINDINGS OF 3
rd
JRM

MANIPUR

Manipur has identified gaps in implementation and taken remedial action on some of the
recommendations of the 2
nd
JRM which has resulted in perceptible change in the pace of
implementation; program management structures have been established, orientation of staff
undertaken and processes have been initiated for operationalising facilities. However, in
spite of adequate manpower, the state has not made efforts to rationalise and relocate staff,
an issue flagged off in the 2
nd
JRM. There is an urgent need to streamline funds
management so that it percolates to the district/block level. In the absence of skilled trainers
and infrastructure, capacity building of staff emerges as a problem. The state needs to make
concerted efforts to overcome these challenges urgently in order to achieve the RCH II
goals.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 11.93 Crores Rs. 10.25 Crores
Release Rs. 7.34 Crores
Rs. 1.69 Crores
(till Sept.30, 06)
Reported Expenditure
Rs. 1.81 Crores
Rs. 1.97 Crores
(till Sept.30, 06)
Expenditure/ Release 25% 117%
Expenditure/ Allocation 15% 19%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
2956/7000 beneficiaries
under JSY
4 FRUs fully functional
15/20 target PHCs
functioning as 24x7
Ensure regular supply
of DDA kits /other
equipments to staff
CHILD HEALTH
IMNCI not initiated
Targeted 28 new born
care corners
Organize village health
days in insurgency
free areas
Plan school health
programs in the valley
areas
FAMILY PLANNING
CPR for IUD declined
between NFHS 2(6.8)
and 3 (5.4)
IEnsure supply and
repair of laproscopes
Train para medical
staff on lap techniques

- 178 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
GOVERNANCE
Required orientation of
SPMU and DPMU staff on a
priority basis
Review program
management, need to
streamline urgently
State govt. needs to
comprehend the concept
and vision of NRHM

SPMU staff recruitment
yet to be completed

DPMU staff recruited as
per ToR. DPMUs in place
in all districts

Orientation of DPMUs
completed

Review personnel policies
(with reference to posting of
staff in remote, risky areas)
Optimal utilization and
rationalization of existing
staff
Redeploy technical
staff in peripheral
facilities urgently
TRAINING/ IEC/ NGO INVOLVEMENT
More pro-active
collaboration required with
NGOs to leverage program
impact
Lack of training resources
in the state
Required pro-active
collaboration and
follow up with RRC-NE
INNOVATIONS

EQUITY AND ACCESS
Accelerate Implementation
of Tribal health program
No headway on proposed
Tribal RCH plans

OTHERS
Concentrate program
interventions in insurgency
free districts
Quality of interventions
needs major improvement

DAPs completed for 4
districts
Improve access in
insurgency prone
/remote areas through
mobile medical units




- 179 -


RCH II: FINDINGS OF 3
rd
JRM

MEGHALAYA

Plagued with a host of problems, Meghalaya continues to lag behind in implementation of
RCH II among the North Eastern states. The state has not made adequate efforts to address
the major bottlenecks inadequate program planning, dissemination of basic information and
awareness, lack of motivation, understanding and involvement of program staff identified
during the second JRM. The state fares poorly in the RCH goals, with a poor IMR of 49
(SRS 2005) and the worst TFR (3.8, NFHS 3 2005-06) amongst the North Eastern states.
The corresponding outcome indicators also indicate inadequate progress over the years.
Meghalaya needs to urgently review and revamp the program planning and implementation
strategy, and take prompt action on the problems identified and suggested actions.
Technical assistance is required from GoI and RRC to find a way forward.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 9.00 Crores Rs. 9.98 Crores
Release Rs. 4.50 Crores
Rs. 0 Crores
(till Sept.30, 06)
Reported Expenditure
Rs. 0.68 Crores
Rs. 1.13 Crores
(till Sept.30, 06)
Expenditure/ Release 15% ----
Expenditure/ Allocation 8% 11%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Transformation of PHCs
and CHCs to FRUs needs
to be taken up on a priority
basis
1/3 FRUs operationalised
3 DHs fully functional
8/20 PHC upgraded to
24X7

Train ASHAs by NGOs and
RRC

Ensure rationalization of
existing manpower across
all health facilities, specially
in peripheral institutions
No action so far on
rationalization of
manpower
Relocate manpower to
serve remote areas
beyond Shillong

Activate RKS to address
major issues in hospital
management

Low institutional delivery
(29.7%, NFHS 3); non
functional facilities
2000/6000 beneficiaries
in JSY
Ensure all facilities are fully
functional before year end

- 180 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
Very high MMR (above
400)
Utilize emergency
contraceptives for
reducing MMR
CHILD HEALTH
3 districts selected for
implementation of IMNCI

Organized regular
monthly health days in
collaboration with AWW
FAMILY PLANNING
Highest TFR,high unmet
need (35.1%, NFHS 3)
and low CPR (18.5%)
IUD training initiated in 3
districts
Improve access and
coverage of family
planning services through
IEC (use local media and
specific BCC)
GOVERNANCE
Develop workforce
management plan and
speed up DPMU staff
recruitment
Enhance staff skill through
capacity building
7 DPMU staff recruitment
completed

TRAINING/ IEC/ NGO INVOLVEMENT
Collaborate with Church for
community sensitization and
awareness
No progress on MNGO
scheme


Disseminate IEC for
program awareness
IEC materials developed
in local languages and
disseminated

Urgent need for staff
orientation and training in
MIS

Slow progress on training
(no progress on
anaesthesia training,
TOT and SBA training)

EQUITY AND ACCESS
Explore alternatives (low
cost, health facilities) in
remote areas through Army
and Church partnership
No initiative so far on
Army church partnership
Establish dialogue with
Army bases in the State
for improving access to
health services
Select ASHAs from low
performing districts and
vulnerable communities
Loopholes in selection of
ASHAs from underserved
and unserved areas




- 181 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled
88%
2 c. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%

0%
3 % of sampled state and district programme managers aware of
their responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
14.28%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
6 % of districts reporting quarterly financial performance in time
71.5%
7 % of district plans with specific activities to reach vulnerable
communities
---
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
0%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures

10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month
0%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services
25%
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
85%
13 M & E Triangulation



- 182 -


RCH II: FINDINGS OF 3
rd
JRM

MIZORAM

Mizoram has achieved the IMR goal for RCH II. The MMR (163) and TFR (2.9) of the state
are also better than the other states of the North East. The state has made efforts to improve
its performance on the suggestions of the second JRM and consequently there has been a
fair amount of progress in the technical areas of the program. However, the state needs to
concentrate on efforts to sustain the achievements made so far. The pace of implementation
has declined in the past year and this needs to be looked into. A few areas for action are
establishment of fully functional management structures and up scaling of the immunization
programme which has declined in performance over the years. The state has the potential to
be a high achiever in RCH II. A target and outcome-oriented approach along with a focus on
qualitative aspects is required in ensure the same.
Financial progress
FY 05-06 FY 06-07
Allocation Rs. 13.57 Crores Rs. 4.83 Crores
Release Rs. 11.82 Crores
Rs. 0.00 Crores
(till Sept. 30,06)
Reported Expenditure
Rs. 8.85 Crores
Rs. 2.23 Crores
(till Sept. 30,06)
Expenditure/ Release 75% ----
Expenditure/ Allocation 65% 46%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Institutional deliveries 72%

Male and female health
worker posted in all
subcentres
Target for 90%
achievement in
institutional deliveries
through 2
nd
ANM.

670/943 ASHAs
recruited.
Prioritise training of
ASHAs to make them
fully functional
5/9 FRUs are fully
functional




Expedite processes for
making FRUs
functional by mid 2007
Ensure at least one
functional facility in
every block

Shortage of ANM for
filling the position of the
2
nd
ANM
Recruit GNM/nurses in
fill vacant position of
the 2
nd
ANM
Focus on maternal
health services (ANC,
PNC) through village
health days.

- 183 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
CHILD HEALTH
Delay in IMNCI trainings


Two IMNCI districts: 6
MOs trained in IMNCI


Plan a time frame for
completion of the
trainings.
Focus on IMNCI
training of personnel at
the facility level. RRC
to coordinate the
same.
Immunization coverage
dropped sharply between
NFHS 2(59.6%) and
NFHS 3 (46.4%)
Accelerate
immunization pro-
actively; fast track
activities before onset
of monsoons
Promote immunization
through regular village
health days. ASHAs
need to monitor
immunization and
follow up on mothers
FAMILY PLANNING
Unmet need for spacing
methods increased from
11.7(NFHS 2) to 12.4 in
NFHS 3
Promote spacing
methods through IEC
campaigns
Train MOs, and ANMs
on IUD insertion
Organise weekly fixed
days for family
planning services.
GOVERNANCE
Expedite the recruitment of
DPMU staff and plan for
recruitment of SPMU
urgently
Recruitment of SPMU
staff in process.
Accounts Manager and
DEOs recruited in all
DPMU
SPMU and DPMUs
need to be in place
and fully functional by
February, 07
TRAINING/ IEC/ NGO INVOLVEMENT
Promote immunization
campaign through IEC
No progress on SBA and
anaesthesia training



Explore multi skill
trainings to be
conducted through
local hospitals and in
medical colleges of
Kolkata (through RRC)
Ensure certification for
trainings conducted in
the local hospitals
EQUITY AND ACCESS
Prepare action plan to
prioritize access to services
of vulnerable groups.


- 184 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
OTHERS
Collaborate with donor
partner to address capacity
building needs for M & E



Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 96%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
Nil
100%
3 % of sampled state and district programme managers aware of their
responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
60%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
<10%
6 % of districts reporting quarterly financial performance in time 100%
7 % of district plans with specific activities to reach vulnerable
communities
100%
8 % of sampled outreach sessions where guidelines for AD syringe use
and safe disposal followed
100%
9 % of sampled FRUs following agreed IP and health care waste disposal
procedures
44%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 50%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 33%
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
62%
13 M & E Triangulation


- 185 -


RCH II: FINDINGS OF 3
rd
JRM

NAGALAND

Nagaland has made considerable efforts to improve implementation of RCH II program,
which is reflected in the outcomes. The strategies of communitization and innovative
collaboration with diverse stakeholders have leveraged the impact of the program at the
grass root level. However, the state needs to take action on solving the manpower crisis
urgently since it has far reaching impact on the pace of program implementation. Program
monitoring and capacity building strategies needs to be reviewed in the light of the slow
progress on the same. It is vital to ensure that resources percolate to the lowest
administrative levels for optimum utilization. Fund management and accountability needs to
be improved.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 10.36 Crores Rs. 8.68 Crores
Release Rs. 6.61 Crores
Rs. 0.00 Crores
(till Sept.30, 06)
Reported Expenditure
Rs. 3.75 Crores
Rs. 1.29 Crores
(till Sept.30, 06)
Expenditure/ Release 57% ----
Expenditure/ Allocation 36% 15%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
759/1400 ASHAs trained
20 PHCs functioning as
24x7
Nurses training school
planned
ANMs posted in 97 sub
centers
Monitor performance
of ASHAs through
RRc
Implementation of JSY
has been slow
Ensure full
functionality of health
facilities for proper
implementation of JSY
CHILD HEALTH
3 districts identified for
IMNCI.
40 MOs trained in IMNCI
Organize school health
programmes regularly
Immunization coverage
21%, lowest amongst the
NE states)
Immunization sessions
held regularly and
coverage improved
Fast track
immunization before
onset of monsoons

- 186 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
FAMILY PLANNING
CPR for female
sterilization declined from
12.3 in NFHS 3 to 9.9 in
NFHS 2
Prevalence of IUD has
declined from 7.7 to 5.2
between NFHS 2 and 3.
Improve CPR through
communication
activities using various
channels
GOVERNANCE
SPMU and DPMUs in
place
District RCH officers
functioning as DPMs
Qualification of Accounts
personnel are not in line
with ToR

TRAINING/ IEC/ NGO INVOLVEMENT
Plan training calendar and
develop training schedules

Orient PRI, Village Councils
and Womens wing on JSY
and RCH II

Train technical/non
technical staff through RRC
-NE
Slow implementation of
training: lack of resources
Need to plan
strategically for up
scaling training
activities with an
outcome-oriented
approach
INNOVATIONS

EQUITY AND ACCESS
Utilize Village Health
Committee for wide spread
reach to vulnerable
communities in remote
areas
Village Sanitation
committees formed and
functional in all villages

OTHERS
Identify and appoint
professionals from other
States
Facility survey and
household surveys
completed for district
health plans

Inadequate fund
management at the state
and district level
Resources have not
percolated to the lowest
peripherals
Need to take prompt
action on fund
disbursal and
corresponding
accountability
Seek technical
assistance from RRC-
NE to resolve loop

- 187 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
holes in financial
management
Resolve inter
departmental gaps
through collaborative
efforts


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 100%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
3 % of sampled state and district programme managers aware of
their responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
100%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
6 % of districts reporting quarterly financial performance in time 80%
7 % of district plans with specific activities to reach vulnerable
communities
Nil
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
35%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
73%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 20%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services Nil
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
-
13 M & E Triangulation





- 188 -


RCH II: FINDINGS OF 3
rd
JRM

ORISSA


Orissa has shown good progress on health indicators. However, the state needs to align its
IMR and MMR goals to the national goal of <30 and <100 respectively by 2012, and
implement RCH in the state for achieving these goals. Some of the key areas requiring high
attention in the state include full operationalisation of district health missions by ensuring
active participation of District Collectors; strengthening HMIS for collecting disaggregated
data on various services, focusing on monthly health days, and prevention of anaemia in
pregnant women. The utilisation of RCH II funds also needs to improve.

Financial progress
(05-06) (06-07))
Allocation Rs. 57.00 Crores Rs. 69.90 Crores
Release Rs. 40.50 Crores
Rs. 49.57 Crores
(till Sept 06)
Reported Expenditure Rs. 34.42 Crores
Rs. 6.69 Crores
(till Sept 06)
Expenditure/ Release 85 % 13 %
Expenditure/ Allocation 60% 10%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Camp approach to be used
as short-term measure only.
Develop and act on a long-
term plan. Use mobile
medical vans for unserved/
underserved areas.
OPERATIONALISING PHC(N)
ON 24/7 BASIS BY PROVIDING
STAFF NURSES
Placement of Additional
ANMs in 15 % sub-centres
Maternal death enquiry
initiated in 10 districts, in
others being done
Revise state goal for
IMR, MMR & TFR in
line with national goal
of <30, <100 & 2.1
respectively for 2012
Set up systems for
providing
disaggregated data for
institutional deliveries,
immunisation
Track % of institutional
deliveries referred by
TBAs
Use monthly health
days for monitoring
institutional deliveries.
Mosquito nets to be given to
pregnant women during ANC
Distribute mosquito
nets during village
health days.
CHILD HEALTH
Strengthening of the Fixed
Health and Nutrition day
Implementation of IMNCI in 2


- 189 -


JRM 2 RECOMMENDATIONS ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
districts begun, and about to
begin in other 2 districts
ASHA being involved in
IMNCI/ home based neo natal
care
FAMILY PLANNING
Procure laproscopes
Focus on unmet
demand for FP
methods
Emphasise TFR
control to the
districts/CMHOs
GOVERNANCE
Need to ensure that
programme management
staff is effectively deployed
through appropriate reporting
relationships, clarification on
job responsibilities and
appropriate HRD practices.
A Full time Mission Director
Appointed.
All State & District
Programme Management
units in place and fully
functional.
Training of the DPMU staff
completed.
314 Block Programme
Managers being appointed

For District Action Plans
SC/ST populations to be
properly mapped
All 30 DAPs developed
through a consultative
process

State/ district health
missions to be made
operational with active
involvement of Dist
Collectors
TRAINING/ IEC/ NGO INVOLVEMENT
Health messages to be
included in school text books
Village level meetings of
girls, adolescents to be
conducted for effective IPC/
BCC
Conduct health melas/
other IEC activities
more regularly
State formulated a
comprehensive IEC strategy
in 2001, which could be
revisited.

Train doctors, nurses in
dealing with adolescents
Subsequent to training
ensure staff is in positions
where the newly acquired
skills are used.


- 190 -


JRM 2 RECOMMENDATIONS ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
INNOVATIONS
Handing over of facilities
under PPP to be done
quickly
Three Pilot PHCs were run
under (PPP) with financial
support of Interact Worldwide
and EC-SIP
Advertisement issued for
NGOs to scale up PPP across
the State. 40 PHC / CHC to
be covered under the Initiative
during 2007.
40 hard to reach sub centres
to be managed by on pilot
basis under PPP

Need to demonstrate that
GIS has led to improved
decision making.
GIS maps being developed
for urban areas

M&E AND TA REQUIREMENTS
Field level inspection system
needs strengthening. LHVs
to perform regular
supervision and monitoring

Monthly meetings of ANMs at
PHCs, PHC staff at CHCs
and CHC staff at District level
to be conducted regularly
every month for performance
review

OTHER ISSUES
Complete facility surveys for
all districts.

Improve funds
utilisation / financial
reporting from districts
Development partners to
assist the state in
development of procurement
policy/ systems.
Hindustan Latex Ltd. could
be asked to assist in
procurement
Procurement to be
decentralised at districts


- 191 -


RCH II: FINDINGS OF 3
rd
JRM

PUDUCHERRY


Puducherrys TFR at 1.8 (SRS, 1998) is the best in the country. The IMR (SRS 2005) of 28
is considerably lower than the national average of 58. At the same time most of its outcome
indicators are better than other UTs e.g. among the UTs, Puducherry has the best figures for
skilled care at birth (98.5) and institutional deliveries (97.2). It even has the best figures for
full immunization coverage (children 12-23 months) at 89.3%. One area of concern is
antenatal check ups since proportion of women getting full antenatal care is only 28.8%.
Under RCH II, Puducherry has been regularly conducting monthly health camps. The UT
has also taken the initiative to improve routine immunisation by extending house-to-house
immunisation services at all the 77 sub-centres. In addition Puducherry has strengthened
Neonatal Care Services at 2 CHCs and 4 PHCs. The UT has also shown progress in terms
of appointing doctors and SBA training for staff nurses.

Financial progress
(05-06) (06-07)
Allocation
Rs. 1.00 Crores Rs. 1.93 Crores
Release
Rs. 0.87 Crores Rs. 0.89 Crores
(till Sept 30, 06)
Reported Expenditure
Rs. 0.13 Crores Rs. 0.33 Crores
(till Sept 30, 06)
Expenditure/ Release 15% 37%
Expenditure/ Allocation 13% 17%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH






15 RCH camps
conducted
32% of the JSY funds
have been utilised.
Delivery rate in FRUs is
very poor
116 deliveries have been
conducted in 24X7 PHCs



Try to improve quality of
services in FRUs and
inform people about the
facilities available in
FRUs
CHILD HEALTH
Routine immunization
service extended to 77
SHC
Neo natal care
strengthened in 2 CHCs
and 4 PHCs

State must expedite TOT
for IMNCI.
FAMILY PLANNING
15 camps have been
conducted


- 192 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
25 pvt. hospitals
accredited to provide
sterilization services.
GOVERNANCE
SPMU established and 6
consultants appointed.
DPMUs established in all
4 districts
Pre-induction training
given to all the
consultants

The issue of problem in
recruiting of doctors -may
be raised with the state
government.
4 specialists appointed.
TRAINING/ IEC/ NGO INVOLVEMENT
24 staff nurses trained in
SBA


Prepare training plans for
life saving anesthesia for
MOs
OTHER ISSUES
Try to conduct all the
targeted camps by 31
st

March 2007.


- 193 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 94%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
3 % of sampled state and district programme managers aware of
their responsibilities
60%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
100%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
5%
6 % of districts reporting quarterly financial performance in time 100%
7 % of district plans with specific activities to reach vulnerable
communities
80%
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
90%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
100%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 40%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services ---
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
100%
13 M & E Triangulation ---

- 194 -


RCH II: FINDINGS OF 3
rd
JRM

PUNJAB


Financial progress
FY 05-06 FY 06-07
Allocation Rs. 29.00 Crores Rs. 36.12 Crores
Release
Rs. 17.42 Crores Rs. 14.20 Crores
(till Sept 06)
Expenditure Rs. 5.02 Crores Rs. 3.89 Crores
(till Sept 06)
Expenditure/ Release 29% 27%
Expenditure/ Allocation 17% 11%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
FRU operationalisation not
per guidelines. Actually only
providing Basic Obs Care,
and dont have blood storage
facility. Develop partnership
with Red Cross for blood
storage.
In 50 PHCs, labour room
and minor OT being
constructed.
MO posts at lower level
facilities filled up
Block PHC posts filled up
SN posts filled up
Incentive for early
registration of pregnancy
and ANC
19 master trainers on SBA
trained
Kit A & Kit B tendered.
Monthly VHN days being
organised at Anganwadi
centres.
8294 JSY beneficiaries.
Using accredited private
facilities also.

CHILD HEALTH
Step up pace of IMNCI
trainings
IMNCI being implemented
in 3 districts

GOVERNANCE
Speed up recruitment of
DPMUs
No progress on recruitment
of PMU staff
100% RKS registered

FINANCIAL MANAGEMENT / PROCUREMENT
Any clarifications on
procurement need to be done
by the governing body of the
society.


- 195 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
Involve PHS Corporation
TRAINING/ IEC/ NGO INVOLVEMENT
Several RCH I trainings are
still being conducted.
Increase pace of trainings
based on the new modules.
6 districts being covered by
3 MNGOs.

EQUITY AND ACCESS
115 urban slum areas
identified. Multipurpose
health worker recruitment
completed in 12 districts.

PNDT & Sex Ratio
Focus to be given for
monitoring sex ratio at birth,
enforcement of PNDT, and
gender issues

OTHERS
TA requested:
Expertise for introduction of
Inventory Management
System for logistics.
Funds and expertise for
establishment of warehouses
at state, district & block levels.
Validation of data.
Funds & expertise for
undertaking KAP study under
BCC.
Design of training modules
based on a training need
assessment.
182 computer systems
installed at district and
block levels
69 computer operators
recruited.



- 196 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 95%
2 c. % of districts having full time programme manager for RCH
d. Administrative and financial powers delegated
---
3 % of sampled state and district programme managers aware of
their responsibilities
---
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
---
5 % of district not having one month stock of
d. Measles vaccine
e. OCP
f. Gloves
0%
6 % of districts reporting quarterly financial performance in time 90%
7 % of district plans with specific activities to reach vulnerable
communities
100%
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
---
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
100%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month ---
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services ---
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
---
13 M & E Triangulation ---

- 197 -


RCH II: FINDINGS OF 3
rd
JRM

RAJASTHAN

Rajasthan has taken several initiatives to set up programme management and strengthen
institutional arrangements for RCH II. However, these need to impact on better service
delivery to the people. The state needs to realign its MMR, IMR goals to national goals of
<100 and <30 respectively by 2012, and speed up its pace of implementation for achieving
these.
Financial progress (05-06)
FY 05-06 FY 06-07
Allocation Rs. 87.50 Crores Rs. 105.76 Crores
Release Rs. 40.00 Crores
Rs. 69.60 Crores
(till Sept 06)
Reported Expenditure Rs. 22.72 Crores
Rs. 10.47 Crores
(till Sept 06)
Expenditure/ Release 57% 15 %
Expenditure/ Allocation 26% 10%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Promote JSY at village level
to encourage institutional
deliveries; conduct
workshops at villages,
blocks, in functional
institutions; make JSY a
political issue at community
level.
ANMs claiming home
deliveries under JSY.
Monitoring to be
strengthened at SHCs.
90% of targeted JSY
beneficiaries covered till
December 06.
JSY help line started in the
state
Provide JSY benefits to
all women coming to
health institutions,
irrespective of them
having undergone
ANCs
Provide post operative care
for mothers through effective
tracking
365 health facilities including
DH, CHC, PHC, CHCs being
developed as 24X7 facilities
Procure and distribute
RCH kit A and B
Distribute ASHA kits
Provide pregnancy
detection kits to ASHAs
Red Cross has assured
support in providing blood
storage facilities in all
districts. State to work
towards forming partnership
with Red Cross
Training for blood storage unit
underway

Integration of AYUSH to
increase choice for people.
Roles of AYUSH and
allopathic practitioners to be
clarified


- 198 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
State to revise targets
for MMR, IMR so as to
align it with national goal
for 2012
CHILD HEALTH
Immunisation 27%
Panchamrit campaign for
immunisation of left out
children
Cold chain strengthened
Alternate vaccine delivery in
all districts
IMNCI being implemented in
9 districts
Malnourishment treatment
centres at 7 DHs
Appoint retired
ANMs/nurses on
contract as alternate
vaccinator

Budget/PHC for alternate
vaccine delivery very low
Use flexi pool for
supplementing alternate
vaccine delivery funds.
GOVERNANCE
State Human Resource
Management Agency to
maintain a panel of eligible
staff for filling up positions
falling vacant. SIHFWs
capacity would need to be
strengthened to fulfil this role
Key observations of Goa
conference: early
confirmation of contract staff;
integrate old and new staff
through appropriate reporting
system and clear job
responsibilities, to be
implemented
State to spell out equivalent
levels of contract staff in
government hierarchy

An external human resource
management agency in the
process of being appointed

TRAINING/ IEC/ NGO INVOLVEMENT
After training the
functionaries to be posted
such that they provide
services in the area of
training. Computer data base
of trained persons to be
maintained and used for their
posting.


- 199 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
Medical colleges to be
involved in training. SBA,
EmOC training to be included
in MBBS curriculum
TBA training to be used as
stop gap arrangement till
SBAs are all in place and
trained. TBAs to play the role
of assisting ANMs during
delivery

National level TV
advertisement content could
be used by state. Sector
level meetings to be
convened to train ANMs,
ASHAs in health messages
and IPC. Use IEC tools for
awareness generation
regarding child marriages,
institutional deliveries. Use
health messages in
textbooks for schools.
IEC money from next year to
be disbursed under common
flexible pool
Swastha Chetna Yatra, and
IEC cum mop up campaign
conducted in entire state with
active participation of health
dept staff and the public
representatives

FINANCIAL MANAGEMENT
As decided in the Goa
conference: for simplifying
financial procedures and
avoiding delays, DCs to
approve the expenditure
under various heads, but
cheque signing authority for
the approved amount to rest
with CMHO/ CS. States to
communicate this to the
districts.

INNOVATIONS
Next level of institution for
referral services to be
identified for all facilities.
Referral institutions to be
prepared to receive referred
cases
Home visits by ANM/AWW
for new born care to be
carried out


- 200 -


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
EQUITY AND ACCESS
State to identify the
proportion of SC/STs among
ASHAs
ASHAs to compensated for
identified services
Ensure timely payment
for ASHAs, provide id
cards for ASHAS, and
link ASHAs to functional
facilities
M&E AND TA REQUIREMENTS
State to provide documentary
evidence for achievement of
core 13 indicators as
specified in enclosure 4 of
JRM process manual
Data should be provided on
13 process indicators: refer
Annex II of JRM process
manual

OTHER ISSUES
Donor partners to assist
states with strengthening
procurement and logistic
systems
Army has proposed to
support health care through
running PHCs, providing
doctors on part time basis at
health facilities, training of
health department staff,
helping women in distress
through counselling. State to
make use of this offer



- 201 -


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 61%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
89%
3 % of sampled state and district programme managers aware of
their responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
100%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves

0%
0%
100%
6 % of districts reporting quarterly financial performance in time 81.25%
7 % of district plans with specific activities to reach vulnerable
communities
0%
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
90.9%
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
50%
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 22.2%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 10%
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols

13 M & E Triangulation


- 202 -


RCH II: FINDINGS OF 3rd JRM

SIKKIM
Sikkim has achieved the IMR and TFR goal for RCH II and has demonstrated considerable
progress in the corresponding outcomes. The state has made strides in program
implementation since JRM 2, in spite of several inherent constraints like lack of skills in
program planning and management, non-availability of technical specialists and training
infrastructure. However, the challenge is to sustain the outcomes achieved so far. Some
areas for improvement are management systems at the block and district levels, monitoring
of outcomes of all interventions and capacity building of staff at all levels. It will be
worthwhile to revisit the training strategy, identify alternatives and take appropriate action on
a priority basis. There is scope for further improvement in fund utilization in technical areas.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 1.82 Crores Rs. 2.42 Crores
Release Rs. 1.00 Crores
Rs. 1.88 Crores
(till Sept. 06)
Reported Expenditure
Rs. 1.03 Crores
Rs. 0.45 Crores
(till Sept. 06)
Expenditure/ Release 103% 24%
Expenditure/ Allocation 56% 19%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH

Explore availability of
specialists form other States
on a contract basis. Focus
on quality of care in FRUs

Expedite construction of
new born corner in the
CHCs

Lack of specialists for SM
consultants
450/665 ASHAs selected
Induction /orientation of
ASHAs ongoing
NBCC in place in all
CHCs
41 RCH camps organized

Prioritize implementation of
JSY and health camps

JSY promoted pro-
actively: 1168/1900
beneficiaries
Organize health
melas for awareness
on JSY and other
activities
Capacity building of ANMs
needs to focused at the
earliest

CHILD HEALTH
2 districts selected for
implementation of IMNCI
9 MOs trained on IMNCI
95% coverage for BCG
Monitor implementation of
village health days
Ensure presence of ANM
during the same


- 203 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
Target 95% immunization
coverage for all vaccines

Organize school health
days in all districts
FAMILY PLANNING
4/9 NSV camps
organized
376/735 cases of NSV
Trainings yet to be
initiated for para medical
staff
Expedite training on NSV
and IUD for para medical
staff
GOVERNANCE
Need to source qualified
personnel through media
and network
Prioritize recruitment of
Programme Managers by
exploring various sources
SPMU staff recruitment
completed.
11/12 DPMU staff
appointed (All DPMs in
place)
Orient/ train PMU staff on
a priority basis
TRAINING/ IEC/ NGO INVOLVEMENT
Comprehensive training
plan to be developed for
West Bengal may be
explored for training
facilities

No progress on
anesthesia and SBA
training
3 MNGOs selected

Complete multiskill
training of MOs at the
earliest
EQUITY AND ACCESS
Formulate plans for service
delivery in remote areas
through NGO/ CBO
partnership
Pro-active collaboration
with NGOs for service
delivery in uncovered
areas

OTHERS
No progress on district
action plans
Complete district action
plans before year end
Involve block level
committees in district
planning processes




- 204 -


RCH II: FINDINGS OF 3
rd
JRM

TAMIL NADU

Tamil Nadu showed a clear focus towards managing RCH II outcomes. States TFR at 1.8
(NFHS 3, 2005-06) is the best in the country. Performance in terms of MMR and IMR is also
encouraging. The IMR (SRS 2005) of 37 is considerably lower than the national average of
58. The states MMR is 134 (SRS 2001-03), well below the national average of 301. Keeping
all these in mind the state needs to sustain its progress.

Financial progress
(05-06) (06-07)
Allocation Rs. 74.00 Crores Rs. 106.56 Crores
Release
Rs. 61.38 Crores Rs. 71.03 Crores
(till Sept 30, 06)
Reported Expenditure
Rs. 52.49 Crores Rs. 9.85 Crores
(till Sept 30, 06)
Expenditure/ Release 86% 14%
Expenditure/ Allocation 71% 9%

Component wise observations and suggested action points are as follows:

JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
780 PHCs with 3 staff
nurse
65% of the JSY money
utilised
Family health clinics
(RTI/STI) in BEmONC
PHCs
Additional funds required
for JSY







State may reallocate
unutilised funds from
other heads to JSY after
taking the consent of GoI
FAMILY PLANNING
The state needs to focus
on NSV and IUD
Try to improve the
awareness of EC through
campaigns
GOVERNANCE
1419 PHCs, 22 DHs and
138 taluka hospitals
registered for RKS.
Try to have RKS in
medical colleges as well.
The state needs to
immediately send the
pending UCs to the
centre.
Try to put SPMUs and

- 205 -


JRM 2
RECOMMENDATIONS
ACTION TAKEN AND
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
DPMUs in place by 31
st

March 2007.
TRAINING/ IEC/ NGO INVOLVEMENT
ISM, MO training, pre
service training for health
officers
Immunization training,
IMNCI training
Paediatric nurse training
Maternity nurses training
BEmONC training- pilot
training completed
LS anaesthesia, LS Obs,
skill trainings for doctors
MVA, tubectomy, NSV,
Laparoscopy training.

EQUITY AND ACCESS
Try to recruit link workers
(equivalent to ASHA) in
tribal areas
OTHER ISSUES
95% of the targeted health
camps held
Try to conduct all the
targeted camps by 31
st

March 2007.


- 206 -


RCH II: FINDINGS OF 3
rd
JRM

TRIPURA

Tripura has made considerable progress since the last JRM. Programm management
arrangements have been strengthened and financial management appears to have
improved. The state has made efforts to improve awareness on services and service
delivery through effective collaboration with the PRIs. However, the health infrastructure
needs to be developed and manned by adequate and skilled personnel for ensuring
complete activation of services. Quality of care in the facilities needs to be taken into
consideration. Monitoring of interventions and outcomes is vital. Capacity building /
orientation of staff should be a priority. The state needs to improve fund utilization especially
in the technical areas.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 9.67 crores Rs. 13.18 Crores
Release Rs. 6.00 crores
Rs. 6.19 Crores
(till Sept.30, 06)
Reported Expenditure
Rs. 2.02 crores
Rs. 0.55 Crores
(till Sept.30, 06)
Expenditure/ Release 34% 9%
Expenditure/ Allocation 21% 4%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
80% ANMs in place in
sub centres.


Ensure presence of
ANMs in all facilities.
1229 ASHAs / Link
workers in two districts.
Training of ASHAs
planned in February
96 RKSs registered
Referral funds for
transportation disbursed
to districts and health
facilities
2 DHs functioning as
FRUs
37 RCH camps organised
in 15 villages through
helicopter services
Promote services
through village health
days and health melas.
Monitor outcomes and
quality of health days.







- 207 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
Slow progress in JSY Promote institutional
deliveries through
extensive IEC
Make facilities fully
functional
Lack of specialists for
operationalising FRUs
Explore recruitment of
specialists from West
Bengal
Plan for augmentation of
manpower by Mission
Steering Group
Mandatory to post
graduates doctors in rural
areas
Review manpower
distribution in rural areas
Implement transfer and
posting policy of ANMs
and MOs in rural areas
CHILD HEALTH
Lack of baby warmers in
NBCC


NBCC needs to made
functional (availability of
baby warmers essential)

Village health days
initiated in primary
schools
Organize village health
days in Anganwadi
centers
Focus on child nutrition in
collaboration with ICDS
FAMILY PLANNING
Slow progress on NSV (4
NSV melas planned in
February)
Utilize innovative IEC for
promotion of NSV
GOVERNANCE
Recruitment of 3 SPMU
staff completed.
Recruitment of 12
sanctioned positions in
DPMUs completed
Induction training of staff
completed by RRC-NE
Pro-active collaboration
required from the state
with RRC-NE, GOI and
DPs to strengthen
PMSUs.
TRAINING/ IEC/ NGO INVOLVEMENT
Assess training needs and
develop plan accordingly
Inadequate skills of
technical staff
Training started for
ANM.SBA training
planned in February
NGOs identified for
Fast track multiskilling of
doctors
Develop partnership with
IGM, TMC, NIFHW,
SIFHW and other
technical institutes in

- 208 -


JRM 2 RECOMMENDATIONS ACTION TAKEN &
FURTHER ACHIEVEMENTS
SUGGESTED ACTIONS
working in urban slums.
MNGO selected in north
districts
West Bengal for up
scaling training activities
INNOVATIONS
Promotion of PNDT
confined to Agartala
Monitor implementation of
PNDT outside the state
capital
Sensitize PRIs for
enhanced participation in
activities
Initiate community
monitoring of activities
EQUITY AND ACCESS
Develop innovative
strategies to ensure
access to services in
remote risky areas
Establish partnership with
the Army
OTHERS
Improve monitoring and
supervision mechanism.
Plan for effective
implementation of HMIS
Procurement
management needs to be
strengthened


- 209 -


Joint Review Mission - RCH-II Tripura
Field visit report, January 15-18, 2007

A Joint Review Mission led by Ministry of Health and Family Welfare, Government of India
and development partners visited the state of Tripura to review the implementation of the
RCH II programme.

The Mission members included the following:

Ministry of Health and Family Welfare, Government of India
1. Dr. Dinesh Baswal, Assistant Commissioner, Training Team leader
2. Mr. Sanjeev Gupta, Deputy Director, Donor Coordination
3. Mr. Anil Garg, Financial Management Group
4. Ms. Anshu Mohan, RCH II Coordinator, Donor Coordination

Department of Public Health & Family Welfare, Government of Madhya Pradesh
5. Mr. S Saha, Additional Secretary and State Mission Director, NRHM
6. Dr. JN Muhry, Director, Family Welfare Programme
7. Dr. Tapan Kumar Das, Programme Officer, Family Welfare
8. Dr. Ashoke Roy, Secretary, State Health Society
9. Dr. TK Das, CMO, West District
10. Er. Rajat Bhattacharjee, Cold Chain Officer

NE-RRC / ECTA
11. Dr. AC Baishya, Director, NE-RRC

GTZ
12. Dr. Paula Quigley, Programme Adviser, Health Sector Support

European Commission
13. Mr. Dirk Swillens, Deputy Head of Section, Development Cooperation

Programme Management Support Group, Donor Coordination Division MOHFW, GoI
14. Dr. Ravish Behal, Consultant

On January 15, 2007, a briefing meeting chaired by Mr. S Saha, State Mission Director
(NRHM) was conducted. It was attended by Progress of the state on RCH II was presented
to the JRM team followed by discussions on progress factors and key bottlenecks faced by
the state.

Districts for field visits were decided in consultation with the Directorate officials and it was
sought to include two good performing districts, and one predominantly tribal district. Health
facilities covered in these districts is as follows:

West District Amtali, SC, Jumerdepa SC, Pandapur SC, Madhya Gania Mara SC,
Kathalia PHC, Madhupur PHC, Bishramganj PHC, Sonamura CHC, Takarjala CHC,
Bishalgarh SDH and Melaghar SDH,
South District Dhwajanagar SC, Kakhipati SC, Mirza SC, Kakrabon PHC, Maharahi
PHC, and District Hospital
Dhalai District (tribal) Bagaichari SC, Kamalchara SC, Nalichara SC, Noagaon SC,
Kulai PHC, Salema PHC, and BSM Hospital Kamalpur.


- 210 -


A debriefing session chaired by Mr. Saha, Additional Secretary and State NRHM Mission
Director, and attended by Dr. JN Muhry, Director Family Welfare, Dr. Tapan Kumar Das,
Programme Officer Family Welfare, other key functionaries of Govt. of Tripura, and JRM
team members was conducted on January 18, 2007. Observations of the field visits
including key areas for improvement were presented by the JRM team.

The JRM team is thankful to the officials of Govt. of Tripura for extending utmost cooperation
during the conduct of the mission.

PROGRESS ON RCH PROCESS AND INTERMEDIATE INDICATORS

The states progress on RCH II process indicators is provided at Annex 1. While the
programme management arrangements are largely in place and logistics is satisfactory,
financial reporting is not regular and utilisation/provision of services is not adequate.

The states progress on intermediate indicators is provided at Annex 2. The key finding is
the lack of progress on training.

SIGNIFICANT DEVELOPMENTS & PROGRESS OVERVIEW SINCE LAST JRM

- Mission at State & District level has been established.
- PMSU staff in place and functioning, also at district level
- RKS functioning at PHC level
- There is demand for Health Services and this demand is 100% met by Public Health
Institutions.
- Presence of Infrastructure upto the sub centre level and good network of Health
services available.
- HMIS to be put in place shortly (initiative supported by WEBEL).
- Good PRI involvement.
- Fund release good at all levels, and financial reporting has improved.
- SCs using untied funds (Though utilisation is on the lower side) and keeping records.
- Village health days started.
- Agency recruited for facilitating DHAP preparation.
- Many good initiatives started, awareness quite high
- Positive health indicators in latest survey results (NFHS-3)
- Village health day good mechanism to increase awareness and generate demand
There is demand

KEY IMPLEMENTATION ISSUES & RECOMMENDATIONS:

Infrastructure

- Though many renovations have started, facilities are generally in very poor condition
and require improvement in waste disposal, overall hygiene.
- Labour Room Tables are outdated and JRM teams recommends that Labour Room
tables across the State should be assessed and appropriate action taken.

- 211 -


- Laboratory services are inadequate and restricted to sputum testing for TB and
blood smear testing for malaria parasite. Training of lab technicians and provision
of the full complement of services needs to be taken up.
- Radiologists do not have protective gear and radiation level detection instruments.
- There are no sterile gloves available in any facility.
- There is general lack of supervision in the peripheral health / activities and this needs
urgent attention.
- Power back up available in very few places in spite of funds budgeted in the PIP.

Human Resources

- To effectively keep staff in rural areas, must guarantee them urban placement after
2-3 years. This is well implemented in J&K, but requires transparent enforcement.
- Need urgent plan on reallocation of MPWs for unserved areas.
- Lack of specialized doctors especially anaesthetists resulting in no surgical
procedure being under taken even in CHCs and SDHs.
- Inequitable distribution of ANMs/ MPW - Some popular centres have as many as 4 to
5 ANMs as apposed to some sub centres which do not have even one AMN (several
such sub centres in Dhalai district)
- The vacancy (of AMN) at the sub centre is not reflected in the payroll. Working/
deputed to a different sub centre against the sanctioned post (which generally an
inaccessible area).

Financial Management

- Low expenditure may result in no release of funds for next year. Must try to obtain
SoEs and UCs in a timely manner.
- State Finance Manager Post is still not filled. No professional Chartered Accountant
available.
- Low level of expenditure at State and Districts.
- No expenditure on salary to ANM, operationalisation of FRUs, training, hiring of
vehicles for supervision.
- Poor maintenance of accounts at PHC and Sub-Centre level.

Expenditure Analysis: Tripura
Rs. in lakhs
S. No. Activity 2005-06 2006-07 (till
December, 06)
% increase of Exp.
Over last Yr.
1. RCH II 13.06 108.24 729
2. NRHM 34.07 70.23 106
3. Routine Immunization 0 20.47 N.A.
4. IEC 16.41 - N.A.
5. MNGO 0 0 N.A.
6. Pulse Polio 76.03 114.39 51
Total 139.57 313.33 125


- 212 -


FINANCIAL ANALYSIS : TRIPURA
(Rs. In Lakhs)
Funds Released Reported Expenditure
S.
No.
NAME OF
SCHEME 2005-
06
2006-
07
Total
2005-
06
%age
2006-
07
%age Total %age
Unspent Balance
(31-12-2006)
A.
1 RCH-II 600.00 769.00 1369.00 13.06 2.18 108.24 14.08 121.30 8.86 1247.70
2 NRHM 169.90 963.57 1133.47 34.07 20.05 70.23 7.29 104.30 9.20 1029.17
3 ROUTINE IMMUNISATION 17.74 43.05 60.79 0.00 0.00 20.47 47.55 20.47 33.67 40.32
4 IEC 28.83 0.00 28.83 16.41 56.92 0.00 0.00 16.41 56.92 12.42
5 MNGO 0.00 15.00 15.00 0.00 0.00 0.00 0.00 0.00 0.00 15.00
6 PULSE POLIO 76.03 132.98 209.01 76.03 100.00 114.39 86.02 190.42 91.11 18.59
TOTAL:A 892.50 1923.60 2816.10 139.57 179.15 313.33 154.93 452.90 199.76 2363.20
B.
1 MALARIA 18.44 45.16 63.60 0.00 0.00 0.00 0.00 0.00 0.00 63.60
2 IDSP 0.00 65.10 65.10 0.00 0.00 0.00 0.00 0.00 0.00 65.10
TOTAL:B 18.44 110.26 128.70 0.00 0.00 0.00 0.00 0.00 0.00 128.70
TOTAL( A+B) 910.94 2033.86 2944.80 139.57 179.15 313.33 154.93 452.90 199.76 2491.90

- 213 -
Monitoring & Evaluation

- Records are poorly kept in facilities and supervision is lacking.
- Recommend more in-depth assessment of how to simplify registers and gather
relevant data before implementing HMIS project with WEBEL. Should learn from
Andhra Pradesh and West Bengal experiences.
- Poor understanding and therefore poor entry and register maintenance especially at
sub centre level / PHC level.
- The new MIES format not being used.

Training

- The training plans are behind schedule. No skill based trainings (SBA, EmOC, and
Anaesthesia) have started. Additionally, skills of staff in facilities are limited.
- Can develop partnerships with IGM hospital, Tripura Medical College, institutes in
Kolkata and NIHFW to offer the skill based trainings.
- Existing staff have not had refresher training for several years.

Waste Management and Hygiene Conditions

- Hospital Waste Management and Bio Medical waste Management are yet to be in
place across all facilities visited. In some facilities, there are old fashioned pits being
used but some have no waste management at all. Rs. 15 lakhs is unutilized under
RCH II, till date for this activity.
- Lack of Hygiene and cleanliness There is very poor hygiene and cleanliness level
across all facilities visited, the only expectation being Takarjala CHC. There is a
marked absence of any effort also in this direction.

Convergence

- PRIs are well functioning and can be more effectively included in NRHM. They
should play a vital role in the district planning exercises and should be fully informed
on funding availability in their districts to improve expenditure and accountability.
They can also help enormously with community monitoring.

Technical Assistance

- Should make better use of resources available at NE-RRC and GOI. Can also
request for specific assistance from DPs.
- Can extend the range and scope of PPPs, e.g. with the Tripura Medical College, as
mentioned above under training. This will help to improve the quality and variety of
services.

PMSU

- NE RRC and GOI can assist with further orientation of DPMSU staff.
- Would be helpful to employ a HR coordinator to manage all HR issues of contractual
staff.

- 214 -
Lack of Preventive Approach

- Tripura is a Malaria and Diarrhoea prone state yet there are no preventive measures
visible: open drains / open dustbins and (basic level) apathy towards investing in
interventions to prevent these diseases.

IEC

- Still limited efforts on IEC activities. Can outsource more to NGOs. Village health
days should generate more demand but facilities must be able to respond effectively
to maintain trust with the community.
- IEC very low - Health Mela and health day being organized but need to assess their
impact.
- NRHM logo not seen at facilities despite funds released more than one year ago.

Other Problems

- 4768 Cases under JSY during the Financial Year 2006-07. Enhanced publicity may
accelerate the scheme as there is good scope of JSY acceptance.
- Public Private Partnership yet to start
- Rogi Kalyan Samiti though registered have yet not received any funds as of today.
- No supply of IFA from GoI since the last two years. Procurement has been initiated
through TNMSC but this needs to be followed up as IFA tablets were not available in
the facilities visited.

AREAS FOR ACTION AND WAY FORWARD

Procurement

- Re-distribution Policy for drugs procured at State level needs to be deployed in
effective manner. Alternatively, delegate the responsibility of supplying the
medicines to districts etc. by procurement agency itself.
- Procurement decentralisation through empowerment of DHS and RKS may be
taken up at State Mission meeting.

Infrastructure

- Hospital Waste Management techniques need to be established up for managing
appropriate disposal of biomedical waste.
- Outsourcing some aspects of facility maintenance, e.g. laundry, electricians and
clean functional toilet facilities (Sulabh) with approval of RKS
- Ensure access for disabled at facilities
- Develop incentive mechanism (e.g. best maintained & well performing facilities,
ANMs for encouraging Institutional delivery).



- 215 -
Human Resource

- Develop partnerships urgently to provide relevant training, e.g. TMC, IGM hospital,
Institutes in W Bengal & NIHFW, for SBA, EmOC, Anaesthesia, PDC, Lab.
Technician training. Human resources are available but skills need upgrading.
- Professional Development and facility management course courses for CMOs and
MOs in Pvt Medical colleges.
- Reorientation of DPMU on the Public Health Sector.
- HR specialist may be appointed at state health society.
- Manpower distribution needs to be addressed. (ANMs and Specialised Doctors)

M&E

- Greater planning for the HMIS proposal with simplification of registers & improvement
in front line data (look at experiences of states like Andhra Pradesh, West Bengal
and Rajasthan)
- Develop an effective transfer policy to staff rural areas with MOs & ANMs and
enforce it.
- Improve supervision by initiating a policy of peer supervision/review and exchange of
physical area of work amongst state officials.
- Standardisation of formats and registers can look at initiatives in West Bengal.

Financial Management

- Follow up urgently on advances paid to implementing agencies for SOEs & UCs
- Procurement of small items can be managed at district level with approval of District
Level Society / RKS
- Maintain simple petty cash register at PHC & SC to improve accounts maintenance
- The State has to speed up pace of implementation and fund utilisation as this may
impact future financial envelope and fund releases.

Technical

- Newborn care needs more attention (lack of baby warmers in the labour rooms).
- Adolescent health not yet addressed at all, special attention needs to be given to
high percent of anaemic adolescent population in the State.
- Quality of care can be improved significantly with upgrading of skills, equipment & lab
tests
- Develop innovations to reach insecure areas
- Use TA from NE-RRC, GOI and DPs more effectively to strengthen PMSUs
- Anaemia rates high. Haemoglobin testing at PHCs and CHCs needs to be provided.
Nutrition education to be provided in collaboration with ICDS.



- 216 -
Strengthening PRIs

- Sensitization workshop for PRIs at the District level as well as the State Head
Quarters.
- Initiate community monitoring with active involvement of the PRI
- Empowerment in procurement repair and minor renovation activities.

IEC

- Outsource more IEC activities to NGOs
- Increase the number of wall paintings
- Citizen charter to be displayed at the facilities
- Make the NRHM logo more visible
- Use the Health Mela / Village Health Day to explain services available
- Orientation of officers at all levels on NRHM may be done through IEC fund.

Village Health Day

- Village health days to include more preventive health & integrate all aspects of
NRHM
- Enhance PRI involvement with the health workers.
- Use the village health day to create demand for services

Training
- PPP Medical College willing to provide re-orientation training for lab technicians.
- PPP Medical College willing to provide Professional Development Course for MOs
pre- and in-service.
- Multi-skilling of doctors is critical.

Community Monitoring

- Sharing of district fund releases with MLAs so community follow up and monitoring
may be encouraged.
- Community Monitoring Uttarakhand has developed pre-addressed feedback forms
on postcards.
- RKS needs to monitor services. Citizen charters not provided / displayed.

Key observations for facilities visited in West Tripura District are provided at Annex 3.

- 217 -
ANNEX 1

Progress on 13 identified process indicators:

S.
No.
RCH Indicator Level of
Achievement
1 % of ANM positions filled
100%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
100%
3 % of sampled state and district programme managers aware of
their responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
NA
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
6 % of districts reporting quarterly financial performance in time
NA
7 % of district plans with specific activities to reach vulnerable
communities
NA
8 % of sampled outreach sessions where guidelines for AD syringe
use and safe disposal followed
----
9 % of sampled FRUs following agreed IP and health care waste
disposal procedures
NA
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per month 35%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 0%
12 % of sampled health facilities offering RTI/ STI services as per the
agreed protocols
53%
13 M & E Triangulation

- 218 -
ANNEX 2

INTERMEDIATE INDICATORS

Name of State: TRIPURA

Reporting period: October December 2006 (except where specified as cumulative)

S.
No.
Indicator Target as per
PIP (06-07)
Achievement Remarks Source
of data
Infrastructure
1. No. of PHCs upgraded to
provide 24X7 services
1
0 52 MIS
No. of health facilities upgraded to FRUs, fulfilling the minimal criteria as per the FRU
guidelines (at least the 3 critical criteria)
a. District Hospitals
1
0 2 MIS
b. Sub-Divisional Hospitals
1
5 2 MIS
c. CHCs
1
0 0 MIS
2.
d. Others (pl. specify)
1
0 0 MIS
3. % of functional Sub-Centres
2
539 75%
(402/539)
MIS
Programme Management
4.
SPMU in place with 100 %
staff
3
0/3 0 MIS Manager
resigned.
MIS
5.
% DPMU staff in place
4
92% (11/12) MIS
Training
No. of personnel trained in IMNCI
a. MOs
1
31 0
MIS
6.
b. ANMs
1
31 0
MIS
c. AWW
1
62 0
MIS
d. Others (pl. specify)
1
0
MIS
No. of personnel trained in SBA
d. MOs
1
120 0
MIS
e. ANMs
1
120 0
MIS
7.
f. Staff nurse
1
120 0
Will start in Feb.
07.
MIS
No. of personnel trained in IUD insertion
d. MOs
1
0
MIS
e. ANMs
1
120
MIS
8.
f. Staff nurse
1
0
MIS
9. No. of MOs trained in

- 219 -
S.
No.
Indicator Target as per
PIP (06-07)
Achievement Remarks Source
of data
d. Life-saving anaesthesia
skills
1

9 0
MIS
e. EMOC
1
120 0
MIS

f. NSV
1
73
MIS
Maternal Health
10.
Proportion of ANC
registrations in first trimester
of pregnancy
5

MIS
11.
% of planned RCH outreach
sessions held in the quarter
6
48 MIS
Child Health
12.
% of planned Immunization
sessions held in the quarter
6
MIS
Family Planning
13.
% of planned Sterilisation
camps held in the quarter
6
48 54%
MIS
Adolescent Health
14.
Proportion of ANC
registrations in first trimester
of pregnancy for women <19
years of age
7


MIS
Notes:

1. Please give cumulative figure to date since April 2005 in Target and Achievement columns.
2. Numerator is no. of sub-centres with ANM present and working out of the facility. Denominator is
total no. of sub-centres.
3. SPMU is meant to have four core positions: State Programme Manager, State Data Officer, State
Finance Manager, and State Accounts Manager. Please only report how many of these positions
have been filled (as a percentage). Do not count other consultants for this indicator.
4. Numerator is no. of DPMU positions filled. Denominator is no. of DPMU positions required (no. of
districts X 3 positions per district). The core DPMU positions District Programme Manager,
District Accounts Manager, and District Data Assistant.
5. Numerator is no. of pregnant women who registered for ANC in their first trimester of pregnancy
during the quarter. Denominator is total no. of pregnant women who registered for ANC during
the quarter (reference period October December 2006).
6. The denominator for each of these is no. of sessions/camps planned for the quarter as per the
workplan in the approved state PIP.
7. Numerator is no. of pregnant women <19 years who registered for ANC in their first trimester of
pregnancy (during the reference period). Denominator is total no. of pregnant women <19 years
of age who registered for ANC (during the reference period).

- 220 -
ANNEX 3

SUGGESTIONS FOR FACILITIES VISITED IN WEST TRIPURA DISTRICT

Jumerdepa Sub Centre
- Poor understanding and therefore poor record maintenance by the AMN.
- Extremely dirty toilet
- No BP machine
- Untied funds not utilized to ensure cleanliness etc.

Kathalia PHC
- Sanctioned as a 10 bedded facility but works as a 30 bedded one.
- X Ray machine installed but not functional
- Poor understanding and poor maintenance of records
- The new MIS format not being utilised
- Labour rooms needs to be renovated
- Strong participation of PRIs good level of awareness.

Sonamura CHC
- Very low demand
- Very poor hygiene conditions.
- No suction machine in the labour room.
- No baby warmer.
- The emergency room is just a stone slab. There is no bed, mattress, or even a first
aid kit.
- No generator.
- No OT
- Poor attitude of the doctors.
- Waste and refuse lies in the hospital compound.

Melaghar SDH
- Good location and a big facility but poor maintenance.
- No anaesthetist therefore no surgeries being conducted.
- No Bio medical waste management. Garbage lies in open around the facility.
- No privacy in OPD.
- A new labour has been constructed but the door way is so narrow that a wheel chair /
stretcher cannot come through it.
- No proper waste disposal. The refuse lies right behind the newly constructed labour
room in the open.
- It is now proposed that a new labour room will be constructed a little supervision
could have saved a lot of time, effort and money.
- No baby warmer even in the new labour room.

Takarjala CHC
- Marked for upgradation to FRU needs immediate facilitation as it serves a large
under-served tribal population.
- Record keeping much better compared with other facilities visited.
- Labour does not have baby warmer or baby corner
- Under staffed: Only 4 ANMs in place for 11 sub centres.
- Only 1 GNM working - 6 vacant positions.

Madhya Ganiya Mara Sub Centre :
- Needs a new roof (roof is leaking)
- Needs a functional toilet.
- No BP machine.

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- No immunization done in the centre, only outreach services.
- Excellent record keeping by one ANM in position.
- CMO (West District) decided to reward the ANM with new BP machine for
maintaining excellent records even while working in difficult conditions.


Amtali Sub Centre
- Overstaffed - 5 ANMs in the sub centre
- No planning, no understanding of record maintenance.
- Templates (immunization) were not available.
- Centre was visited by Dr. Baishya in August 2006 and the same issues were
highlighted then. However, no action has been taken.

Pandapur Sub Centre
- No BP instrument
- Rented facility
- MPW last trained in 1981
- Dais are undertaking home delivery in the area (TBA)
- Facility was very clean.
- All ANC and PNC cases were being tracked for follow up.

Madhupur PHC
- Overstaffed 43 MPW / ANM deployed for 17 sub centres
- Poor understanding therefore confused and poor record keeping.
- An expired resuscitation kit was kept in the labour room.
- No betadine in supply.

Bishalgarh sub divisional hospital :
- No anaesthetist (hospital catering to 200 + villages)
- Bathroom, labour room, female wards were very dirty.
- No visible IEC.

Bishramganj PHC
- No generator
- Very bad / unusable entrance broken steps
- No antiseptic supply.
- Some confusion about awarding of Benefits of JSY Scheme.
- 7 sub centre out of which 4 are not manned by an ANM.





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RCH II: FINDINGS OF 3
rd
JRM

UTTARAKHAND

Uttarakhand has shown marked progress in most RCH outcomes from NFHS 2 to 3.
However, the state needs to improve implementation as the funds utilisation reported for
quarter ending Sept 06 is as low as 2.4 % of annual allocation. Some of the key areas such
as village health days, home based new born care, school health programmes need to be
given attention. Physical and financial reporting systems need to be strengthened for
improving the programme in the state.

Financial progress (05-06)
FY 05-06 FY 06-07
Allocation Rs. 13.00 Crores Rs. 15.91 Crores
Release Rs. 7.46 Crores
Rs. 9.11 Crores
(till Sept 06)
Reported Expenditure Rs. 3.69 Crores
Rs. 0.37 Crores
(till Sept 06)
Expenditure/ Release 49% 4 %
Expenditure/ Allocation 28% 2%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
State to expedite
procurement of ASHA kits
through delegation of
procurement powers to
districts. Procurement and
distribution of ASHA kits to
be completed by Dec 06
Procurement of ASHA kits in
progress

ASHA training material
modules translated by other
states (MP) to be shared.
GOI to translate other
modules for dissemination to
Hindi speaking states
Modules translated and
printing under progress

Village health days to be
more structured, training
of ASHAs to be
conducted for this
CHILD HEALTH
66% planned outreach
sessions for immunisation

Home based new born
care to be strengthened
through training of field
staff including ASHAs

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JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
ARSH
Carry out school health
programmes
GOVERNANCE
SPMU/DPMU trained
through SIFPSA, and further
training planned through GOI
funds. Same activity should
not be duplicated. Effectively
plan usage of funds from
different sources
SPMU/DPMU training through
NIHFW by using GOI funds.
No trainings were done
through SIFPSA.

Recruit block level
programme managers by
using 6% NRHM funds
Block level staff being
recruited

To overcome shortage of
specialists, explore
opportunities under PPP
BPHC Yamkeshwar being
outsourced under PPP

Panel of wait list candidates
to be maintained for later use
ANMs in position in almost
85% SHCs

Improve funds utilisation
and financial reporting
from districts
TRAINING/ IEC/ NGO INVOLVEMENT
Conduct training for multi
skilling of doctors
FOGSI training for SBA,
Anaesthetists to be scaled up
for making FRUs functional
Anaesthesia training for MOs
being done

Proposal for GNMTC
submitted by HIST to be
looked into
State to seek help from
Indian nursing council for
training of nurses. Need to
develop nursing cadre in the
state
Rs. 1 Crore allocated for
establishing nursing institute
at Dehradun
Strengthen ANMTCs
Orient government staff in
NRHM

Two regional workshops
conducted
District level officials involved
in 4 days orientation training
on NRHM

Enter into partnerships with
neighbouring districts in UP,
as institutions for SBA
training limited in the state

IEC for institutional
delivery/JSY
State has sent leaflets/fliers
through dept of posts, to
every household for
information on JSY and other


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JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
health schemes.
Bus panels developed with
IEC messages
M&E AND TA REQUIREMENTS
Monthly health days to be
monitored. DPs to provide
assistance in monitoring
Monthly health days being
monitored

Improve HMIS.
Establish systems of
collections and
verification of MIS
reports from ANM
upwards
OTHERS
States should support MPW
(M) as all tasks required at
SHC cannot be done by
ANM. Availability of
pharmacists at PHCs to be
ensured
MPW (M) cadre being
revoked
Pharmacists in position at 539
difficult SHCs

State to seek assistance
from USAID for development
of DAPs. To follow procedure
given in process manual for
DAP.
ITAP Constella Futures
providing technical support for
the development of DHAPs in
all 13 districts.
All DAPs to be
developed by March 07
Appraise DAPs and
develop state PIP based
on DAPs
State to allocate some untied
funds to districts under RCH
flexi pool.
Untied fund will be placed at
the Disposal of CMO from 07-
08 onwards.

RKS money should not be
used for non plan
expenditure of the state.
RKS money is not being used
for non plan expenditure

District hospitals to be made
fully functional

Except Champawat and
Bageshwar all district
hospitals functional

Focus on long term
measures through HRD plan.
Coordinate training and
posting of trained manpower
in required facilities
Consultant under EC SIP has
already been appointed for
Streamlining the Medical
Directorate HRD system

Develop operational plan
addressing sustainability for
running of mobile vans for
each district under NRHM
Plan developed and being
ratified by the Executive body
of Society

Empower RKS to recruit
nurses
RKS empowered

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JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
Enter into partnership with
Red Cross for provision of
blood at FRUs.
Organogram including
contract staff to be
developed. Level of contract
staff vis--vis regular staff to
be addressed.
Delegate administrative and
financial powers at
appropriate levels

Release money for NGO
programmes in the state


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 87%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
3 % of sampled state and district programme managers aware
of their responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
100%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
6 % of districts reporting quarterly financial performance in time 100%
7 % of district plans with specific activities to reach vulnerable
communities
100%
8 % of sampled outreach sessions where guidelines for AD
syringe use and safe disposal followed
100%
9 % of sampled FRUs following agreed IP and health care
waste disposal procedures

10 % of 24 hrs PHCs conducting minimum of 10 deliveries per
month
20%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services ---
12 % of sampled health facilities offering RTI/ STI services as
per the agreed protocols
17%
13 M & E Triangulation







- 226 -
RCH II: FINDINGS OF 3
rd
JRM

UTTAR PRADESH

UP is still lagging behind in setting up basic institutional structures, filling up of vacant
positions, training and implementation of various RCH components. Given the poor
indicators for MMR, IMR and TFR in the state, the state needs to give utmost priority to
effective implementation of the RCH II programmes, monitor and report regularly on
programme progress.

Financial progress (05-06)
FY 05-06 FY 06-07
Allocation Rs. 257.50 Crores Rs. 299.73 Crores
Release Rs. 169.72 Crores
Rs. 0.00 Crores
(till Sept 06)
Reported Expenditure Rs. 59.79 Crores
Rs. 38.11 Crores
(till Sept 06)
Expenditure/ Release 35% ----
Expenditure/ Allocation 23% 13%

Component wise observations and suggested action points are as follows:


JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
Need to give attention to
organising RCH camps/
providing mobile medical vans
in minority areas. Polio
immunisation can be taken up
in such camps
RCH camps to be evaluated
RCH camps should serve to
activate under utilised facilities
Funds released for 9876
camps (12 camps per CHC/
BPHC). Camps being
conducted regularly


ISM doctors should not be
allowed to conduct institutional
delivery until they have
undergone SBA training.
ISM doctors appointed at
Block PHCs. They are
allowed to perform normal
deliveries


Promote and monitor monthly
village health days
Sensitise AWW for RTI/STI so
that they can refer such cases

250 units conducting 24
hour delivery services
make one functional
24X7 facility in every
block
Appoint ASHA like
workers for urban
slums

- 227 -
JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
Focus on institutional
deliveries under JSY
Many private practitioners
being challaned under
PNDT
Conduct regular
departmental
meetings and monitor
action under PNDT
FAMILY PLANNING
6 sterilisation camps per
CHC/BPHC being
conducted regularly
Report on
sterilisations in camps/
static facilities
GOVERNANCE
Expedite signing of MOU
ASHAs to get compensation on
time

Urgently place and train
SPMU/DPMU staff
Recruit and training of
SMPU/DPMU staff to
be done on priority
Prepare one
comprehensive plan
for infrastructure for
entire RCH, divide it
year wise for
implementation and
report progress
against that plan
Prepare DAPs for all
districts, reflecting
RCH implementation
from all funding
sources in the district
TRAINING/ IEC/ NGO INVOLVEMENT
Activate ANMTCs. There
should be one functional
ANMTC per district.
State to build a nursing cadre
ANMs, ASHAs, PRI members
to be sensitised on RCH II /
NRHM through sector
meetings
Incorporate SBA
training component in
ANM training

INNOVATIONS
Adequate focus required on
maintenance of facilities
All ANMs to be connected to a
functional health unit. Problem
of most ANMs staying in urban
areas on deputation, etc. to be
addressed
Government could provide
scooter loan to ANMs


- 228 -
JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
M&E AND TA REQUIREMENTS
Effectively utilise Divisional
Commissioners for
strengthening of HMIS.
Front line supervision to be
strengthened through
mobilising LHVs

OTHERS
GOI to send Infection
Prevention & Waste Disposal
guidelines/ UPHSDP
guidelines if available to be
used


Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 98.23%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
3 % of sampled state and district programme managers aware
of their responsibilities
70%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
95.5%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
0%
6 % of districts reporting quarterly financial performance in time 100%
7 % of district plans with specific activities to reach vulnerable
communities
80%
8 % of sampled outreach sessions where guidelines for AD
syringe use and safe disposal followed
70%
9 % of sampled FRUs following agreed IP and health care
waste disposal procedures
NA
10 % of 24 hrs PHCs conducting minimum of 10 deliveries per
month
54.4%
11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 28%
12 % of sampled health facilities offering RTI/ STI services as
per the agreed protocols
100%
13 M & E Triangulation


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Joint Review Mission- RCH-2
Uttar Pradesh
Report of the Visit, January 16-20, 2007


A Joint Review Mission led by Ministry of Health and Family Welfare, Government of India
and development partners visited the state of Uttar Pradesh to review the implementation of
the Reproductive and Child Health II Program (RCH-2).

The Mission members included the following:

Government of India (GOI) - (Ministry of Health & Family Welfare)

1. Mr. Pravin Srivastava (Director-Statistics) - Team Leader;
2. Dr. Sangeeta Saxena (Assistant Commissioner- Child Health);
3. Mr. Rajesh Kumar (Consultant, FMG);

MSG Strategic Consulting Pvt Ltd (MSG) - Programme Management Support Group
(PMSG) - Ministry of Health & Family Welfare

4. Mr. Basavaraj;

Government of Uttar Pradesh (GOUP)

5. Dr. Brijendra Singh (Additional Director RCH);
6. Dr.

European Commission Technical Assistance (ECTA)

7.. Dr. J.N Srivastava;

UNICEF New Delhi

8 Ms. Pranita Achyut;
9. Mr. Prashant Kishore;

USAID

10. Ms. Sheena Chhabra;
11 Dr. Loveleen Johri;
12 Ms. Monique Mosolf;
13. Dr. Sanjeev Upadhaya;

World Bank

14. Dr. Birte Sorensen;
15. Dr. Vikram Rajan;
16 Dr. V.K. Manchanda.

Ms. Renuka Kumar, Secretary, Family Welfare, GOUP chaired the briefing meeting on
16.01.2007. A detailed presentation on the program highlighting the progress, including
additionalities under the National Rural Health Mission, and the implementation bottlenecks
was made by her. The meeting was attended by key representatives from Government of
Uttar Pradesh. The review team also had opportunity for having follow-on discussions on
various aspects of the program.

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The Mission visited two districts, Lakhimpur Kheri and Mirzapur. In Lakhimpur Kheri the
team visited the District Hospital-Male, District Hospital-Female, CHC- Gola; FRU-
Paliakalan; PHCs- Sampoornagar and Behjam and Sub-centre - Neemgaon while the
Mirzapur team visited the District Hospital-Female, District Hospital-Male, CHC-
Vindhyachal; FRU- Chunar; PHC- Kachhawa, Padri, Lalganj, Rajgarh and 4 Sub Centres.

The Mission had a wrap-up session on January 19, 2007 with Mr. A.K. Misra, Principal
Secretary, Health and Family Welfare; Mr. Shailesh Krishna, Project Director, UP Health
Systems Development Project (UPHDP) and Executive Director State Innovations in Family
Planning Services Project Agency (SIFPSA),, Ms. Renuka Kumar, Secretary, Family
Welfare; Dr. S.S. Srivastava, Director General (Family Welfare) and key officials from the
Directorates, Medical and Health and Family Welfare.

The team would like to acknowledge the efforts made by GOUP for facilitating the review
and appropriately responding to various issues raised by the Mission members.

Key Recommendations:

Appointment of a full time State Rural Health Mission (SRHM) Director in accordance
with GOI guidelines;
Establishment of the Programme Management Unit structure at state, division,
district and block level;
Completion of the mapping of human resources and physical structures (including
equipment) and reallocate staff for optimal utilization of resources;
Ensuring that staff at district level and below as well as Non Government
Organizations (NGOs) and Panchayat Raj Institutions (PRIs) are aware of all
available guidelines and sanctions;
Strengthening the District planning process through provision of increasing the
flexibility of funding, ensuring wider consultation and giving attention to vulnerable
groups and specific local needs.

Progress on RCH process and intermediate indicators:

RCH process indicators

In seven out of thirteen indicators the level of achievement was satisfactory. Noteworthy
progress has been made in filling in vacant ANM positions with 98 percent of the sanctioned
ANMs in position. The state also reported no stock-outs for key products during the past six
months. Adequate progress was also reported on sufficient number of deliveries being
performed in 24 hour PHCs, provision of RTI services and use AD Syringe and safe disposal
practices. It is important to note that field-visits did not corroborate the last point and
it was found that disposable syringes were actually been recycled at a facility.

Though two of the three indicators pertaining to program management of RCH II and
delegation of authorities have been met, it is important to note that state had not yet formed
the State Project Management Unit (SPMU) and the District Project Management Units
(DPMU). Also, the Deputy CMOs that have been assigned the responsibility of the program
managers are not fully aware of their responsibilities. Also, only 60% of the districts are
reporting financial performance in time.

For some of the other indicators also, the expected level of achievement was below par.
The operationalization of the First Referral units (FRUs) has been slower than expected and

- 231 -
guidelines for AD syringe use and safe disposal in out reach sessions is below expected
levels.

As regards infection prevention and waste disposal in FRUs as well as triangulation of data,
GOI guidelines are awaited by the state and proper disposal practices were not noticed in
the field.

The details are provided in Annexure 1. The state also provided information on the
intermediate indicators. This has been included under Annexure 2.

Significant developments and progress since last JRM:

The JRM-UP findings are based on observations of field visits to Mirzapur and Lakhimpur
Kheri districts; interaction with program officials at state, district, block and village levels;
ICDS functionaries; local elected leaders; NGO representatives and community members;
as well as information shared during presentations and discussions. The observations of the
teams during the district visits are at Annexure 3

The Mission team observed strong and dynamic leadership at the state-level that has led to
a sense of purpose and commitment at state headquarters. The review team noted progress
on taking key decisions in the following areas:

A decision to recruit additional 35,000 ANMs has been taken to ensure regular
functioning of the sub-centers. The state has ambitious plans to have two ANMs in
25 percent of the sub-centers by December 2008. The Male Multipurpose Worker
(MPW-M) cadre is also being revitalized and over 20,000 MPW (M) will be recruited.
After a gap of more than a decade the state is planning to re-start pre-service training
of ANMs and MPW-M. The state is revitalizing training institutions for undertaking
ANM and MPW-M pre-service training. Recognizing the magnitude of the training
needs, a decision has been taken for also undertaking pre-service training for ANM in
private nursing schools. Furthermore, to accelerate the ANM training there is a plan
to train five batches over four year period by having overlaps between two
consecutive batches.
Nearly 90 percent of the Accredited Social Health Activists (ASHAs) have been
selected and over 60 percent have been provided induction trained. This was
validated during the field-visits.
The state is also pursuing plans to construct 6000 sub-centers under the 11
th
five
year plan and is planning a pilot for prefabricated construction of sub-centers to
expedite construction. To improve accessibility of the sub-centers a decision has also
been taken to locate these centrally and to allocate funds for purchase of land where
necessary.
Recognizing the need for strengthening communication and monitoring, the state
government is considering having a dedicated health statewide area network that
would connect the state directorate with all 70 districts.
To accelerate the implementation of the Mother NGO scheme and improve
efficiency the state has decided to stream-line the contracting and management of
NGOs by outsourcing to 3-4 large reputed NGOs that in-turn will contract and
manage other NGOs.
To strengthen convergence, a village health index register covering information on
health, nutrition and water and sanitation is being introduced.
A performance linked incentive scheme under which performance incentives are to
be provided for provision of services above a certain threshold (i.e. deliveries) and
incentives are also being planned for serving in remote areas.

- 232 -
A system of efficient transfer of funds to all 70 districts electronically has been
established.
A web-enabled system for collecting Statement of expenditures (SOEs) from districts
is being operationlized and is expected to be fully operational by February 2007.
Annual contracts have been awarded for procurement of Drug Kit-A and Drug Kit-B
and these should be available by end February 2007. This is a major improvement
over the earlier six-monthly contracts that lead to stock-outs.

Quality of state and district PIPs:

In 2005-06, 60 districts are reported to have prepared district RCH II PIPs for the period
2005-2010. Copies of about 30 such district PIPs are available in the state FW Directorate.

For 2006-07, districts have not prepared a PIP and neither has the state attempted to
provide flexible funds (to districts). The Government of India RCH II flexible pool allocation of
almost Rs. 300 Crores for 2006-07 has been broken down into 43 activities or state schemes
which are under the purview of 8 nodal officers, each responsible for allocating funds across
districts, preparation of guidelines and subsequent monitoring of implementation for groups
of activities / state schemes. For each such state scheme, each district raises a demand
(i.e. prepares a proposal), which is then reviewed by the concerned nodal officer and finally
approved by a sub-committee of the Empowered RCH II Committee, chaired by the Principal
Secretary. Allocation of funds across districts for each activity/scheme is based on norms
(for example, three RCH camps per Sub Centre, four demand generation meetings per year
per Gram Panchayat at a cost of Rs.175 per meeting, etc.) Districts report back on the
physical activities and expenditure for each scheme. The paradigm shift envisaged in
RCH II in terms of an explicit pro poor focus, need based allocation of flexible funds
with districts setting targets for outcomes and evolving their own need based
strategies and subsequent monitoring of outcomes is yet to take place.

There are at least 4 documents (RCH II PIP for 05-10; RCH II PIP for 06-07; NRHM Draft
Action Plan, dated September 20, 06-07; and Supplementary PIP dated November 11, 06),
which set out the states approach to RCH II for 06-07 and hence it is difficult to assess the
quality of the state PIP. Nevertheless, a brief review of these documents indicates that there
is considerable scope for improvement:

The situation analysis does not highlight key institutional issues such as, (i) background
and tenure of key public health managers at state and districts; (ii) mismatch between
physical facilities, staff and demand; and (iii) poor HRD practices

The programme management structure is still evolving. The DG, FW is acting NRHM
Director although GOI guidelines clearly suggest that the position should be filled by a
full time officer at the level of Special Secretary. Functions such as Human Resources
Development (HRD), Information, Education and Communication (IEC)/ Behavior
Change Communication (BCC)/Intra Communication and Geographical Information
Systems (GIS) have not been reflected in the structure. The SPMU should have
specialists in technical areas as well as IEC, training and Monitoring and Evaluation
(M&E); however their relationships with corresponding staff in the directorates have not
been spelt out. In addition, the SPMU would need to include a number of technical staff
who can fulfill the role of process consultants for the districts as they identify their
specific needs, evolve their innovative strategies to address such needs and implement
and monitor these activities. Reporting relationships for SPMU, DPMU and Block support
staff and their indicators of performance should preferably be spelt out before the unit is
staffed. The strategy for recruiting and ensuring that the SPMU/DPMU staff is effectively
integrated into the health system are yet to be articulated. Further, an institutional

- 233 -
provision for managing the HRD requirements (training, performance appraisal, etc) of
SPMU/DPMU and block level contractual staff has not been made. The above is of
considerable concern, since programme management structures were envisaged
to be in place by April 1, 2005.

The need for programme management systems (holistic monitoring of performance of
districts vis--vis their respective PIPs including a variance analysis) required for
effective functioning of the SPMU has not been addressed.

Criteria for allocation of resources to districts/ blocks and strategy for ensuring that
facilities in areas with poor health indicators are adequately staffed, equipped and
resourced have not been spelt out.

Evidence based strategies for technical interventions

The evidence based strategies as indicated in the RCH-2 log frame have been reflected in
the State PIP, for example, the state has included pre-service training of ANMs and Health
Worker Male, Anesthesia and Emergency Obstetric Care (basic as well as comprehensive)
training for Medical Officers and the state has identified 17 districts for Integrated
Management of Newborn and Childhood Illnesses (IMNCI) and two for Home Based
Newborn Care. Skilled Birth Attendant training has not been included and the detailed action
plan for implementation of technical strategies has not yet been formulated.

Given the resource constraints in the state, the camp approach is still the only practical way
of providing clinical family planning services to the population. However the number of
sterilizations performed, both male and female, in the state has steadily declined over the
past five years. This is unlikely to only be a reflection of the Supreme Court directives
regarding the qualifications of the doctors for performing female sterilizations and calls for
renewed focus on supervision and monitoring the quality of RCH / Sterilization camps.

IUD 380 A that has been newly introduced in the programme was available at all health
facilities visited and all categories of Health Service Providers were aware of its period of
effectiveness.

Under vulnerable groups, an urban health programme and mobile medical unit component is
included in the PIP. Additional contractual ANMs are hired to provide immunization services
in urban slums.

Contractual staff including doctors are placed FRUs, Primary Health Centres (PHCs) and
sub-centres (SCs). There is a provision of contracting services of a specialist. All staff still
spend a substantial part of their time and effort toward the Pulse Polio Programme.

Detailed state level BCC strategy with implementation plan needs to be in place for
generating demand, increased acceptance of technical interventions as well as awareness
of program schemes. More focus is required on inter personal communication (IPC).

Implementation Bottlenecks (state and district):

Appointment of a Mission Director for the NRHM as well as the establishment of the SPMU
and the DPMU is still awaited due to which the Directorate staff responsible for
implementation of the program are severely overstretched and the districts lack the
necessary management and accounting support to do much more than their routine work.
Any additional State level developmental work (optimizing the productivity of existing human
and financial resources; establishment and implementation of quality standards; increasing
intra state communication; preparing a strategy and plan for multi-skilling; strengthening the

- 234 -
district and state planning process; planning for addressing vulnerable groups) would either
have to be contracted out or await the establishment of these structures. Innovative
schemes at the District level are also unlikely to be initiated on a large scale until this
additional support is available.

The state has serious shortages of staff at all levels. From the Directorate to the sub-center
level there are a large number of vacancies; staff holds several posts which reduces
productivity. This is further aggravated by the frequent staff transfers which appear not be
motivated by program needs and results in limited institutional memory regarding the basic
program concept, the process of implementation as well as the different schemes and
alternative opportunities financed by the program. Any measures to address overall Human
Resource Management as well as stabilize program management would facilitate better
program outcomes. Additional measures to accelerate program performance would be a
compulsory induction training module for all joining program managers at state and district
level as well as regular communication of any new/revised scheme/information in the form of
a monthly newsletter to all health staff.

Quality of RCH work:

There is need for greater awareness and sensitivity regarding the need for quality of care for
health services including even the basics like maintenance of general cleanliness in and
around health facilities and keeping stray dogs and other animals away from the premises.

Equipment and drugs There is a mismatch between the placement of manpower and
equipment at facilities. For instance, at Lakhimpur Kheri, three Boyles apparatus were
present at the DH-Male but just across the road the DH Female had no equipment for
anesthesia and were performing Caesarean sections under ether or spinal anesthesia and
despite having the required equipment and human resource, newborn care is not provided.

Maternal health - There has been a mixed response to the Janani Suraksha Yojana (JSY)
scheme in Mirzapur. JSY scheme uptake has been good in the community with deliveries by
JSY beneficiaries increasing at all levels of facilities. However, in Lakhimpur, health
authorities and functionaries are not aware of new JSY guidelines. Even fund disbursement
at PHC and below is low and taking time as fund is kept only at block PHC level. The
community is not aware of this scheme. At the District Hospital Female in Lakhimpur
women with normal delivery are discharged even within an hour of the delivery being
conducted. Provision of services for referral transport is yet to be established in the
communities. A training plan for Skilled Birth Attendants (SBA), anesthesia training and
Emergency Obstetric care (EmOC) needs to be urgently formulated and implementation
initiated.

Infection prevention and waste management: Health care waste management and infection
prevention practices and knowledge are poor at all facilities with no segregation of waste,
poor storage and disposal of sharps and placenta and body parts and lack of mechanisms
for final disposal. However the situation was slightly better at the DH, Mirzapur. In one of the
FRUs of Mirzapur, disposable needles were being recycled with the obstetrician condoning
the practice. The state through Uttar Pradesh Health Systems Development Project
(UPHSDP) is contracting Common Treatment Facilities (CTFs) for collection and final
disposal of hospital wastes.

Newborn and child care: Knowledge and practices of newborn care (pediatrician advising
bath of newborn), including availability of equipment (receiving station, clean warm place
and functional weighing scale) was absent at all facility levels. IMNCI has been planned in
17 districts but the DAPs for these were not received by the team. However the state now
has a team of State Trainers ready. The focus shifts completely to polio immunization during

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the pulse polio rounds and routine immunization shuts down completely during the polio
week.

SC functionality: The sub-centers had good infrastructure in Mirzapur and in Lakhimpur Khiri,
with motivated staff providing ANC, delivery and immunization services at home and the
facility.

FRU operationalization: FRUs are not fully functional as per GOI guidelines in the absence
of equipment and human resource. There are facilities such as Gola CHC in Lakhimpur and
FRU in Mirzapur, where specialists are present without requisite equipment. In Palia FRU, a
fully equipped OT is available without anesthetist. Here, the contractual obstetrician is not
being appropriately utilized.

Public Private Partnership: State shared that guideline for contracting of services of
specialist have been prepared but not this was observed in field.

Non-availability of essential drugs: In the absence of drugs (ORS and Co-trimoxozole),
ANMs are not managing ARI and diarrhea cases.

Monitoring system at state and district levels:

The M&E of the NRHM activities including RCH need more coordination and focused
attention so that it is in synchronization with the overall Management Information and
Evaluation Systems (MIES) framework of the National PIP. Data on the Revised MIES
format is yet to flow from the State Govt. This needs to be sent regularly to the GOI.

Further, the different Programme Officers in the State Government are presently collating
the District-wise performance figures for their respective programmes and there is a need to
identify a nodal M&E officer/establish a M&E cell to be responsible for coordinating the
data flow for all the NRHM/RCH-II related data and indicators. After the compilation, it is also
important that the analysis of the performance data is made available to the field formations
(data provider) so that the institution/individuals relative performance can be known. In the
longer term, data analysis skills would have to be developed at district level and below.

During a discussion with the UPHSDP, it emerged that they are developing software for the
M&E requirements of NRHM in the revised format with active involvement of National
Informatics Centre (NIC). The aim is to make the entire system web-enabled by having a
State-wide Area Network (SWAN) dedicated for the health sector. They are presently
designing systems that capture data from the ANMs and upwards. The required district,
state and GOI report requirements can be generated from this data.


Technical Assistance Requirements:

The state did not in their presentation spell out their TA requirements. Whereas there may
be a need for TA in a wide range of areas the state could prepare a plan of action and
prioritize their TA needs accordingly

Financial Details:

Financial achievement vis--vis PIP is only Rs. 43.54 Crores (15%) till Sept. 2006 (please
refer to figure 1 in annexure-4).
The expenditure on the following items have remained low (as per sept. 2006 FMR):
- Maternal Health 19%

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- JSY 25%
- Sterilization 2%
- Training 6%
- MNGO - 0%
- Adolescent Health 0%
- RTI/STI Services 2%
- Child Health 0%
Till January 2007, 55% of the funds available with the State have been devolved to
Districts.
A decision to send funds to Districts are taking time at State level with delays ranging
from 1-6 months during 2005-06 & 2006-07 (details available till Sept. 2006 which
can be seen in the table in Annexure-4.
Funds are being sent electronically to Districts. But Sanction Orders and Guidelines
are being delayed because of which the benefit of sending funds electronically is
nullified.
SOEs not received from:
- 5 Districts for Oct. 2006
- 7 Districts for Nov. 2006
- 23 Districts for Dec. 2006
JSY is not being implemented in District Hospital. District Hospitals are waiting for
specific G.O. from Government. No benefit is being given to mothers for home
deliveries.
NRHM allocations are expected to go up by 5 times by 2011-12 with UP getting
almost Rs.1,500 Crores. Utilization capacity is already under pressure even with
1/5th of budget.
The Finance and Programme wings seem to be operating in watertight
compartments in the Directorate.
The allocations to the Districts have no relation with DAPs but are determined by the
State.
The financial performance of Districts is not being monitored vis--vis DAPs.
Funds are still being sent on demands from Districts with each demand against each
activity being sent separately. This means that there are a large numbers of releases
leading to unnecessary complexity in fund management especially at the District
level.
There is no expenditure on Health Mela; Incentive to ASHA/Anganwari worker and
Private Providers for Safe Motherhood in 2005-06 & 2006-07
There is no budget for referral transport while the need for this service`was acutely
felt in the field.
Utilization of funds has increased from 26% during 2005-06 to 40% during 2006-07
(up to Dec. 2006)
There is no expenditure on IEC/BCC; Health Mela; Sterilization Camp; Strengthening
of Training institutes & Private Providers for Safe Motherhood during 2005-06 &
2006-07.

- 237 -
Utilization of funds under Routine Immunization is 25%.

Improvements noticed:
Funds are being transferred to Districts electronically
A web based on-line solution is being implemented to get the SOEs electronically
from Districts (22 Districts have defaulted in Dec.06)
The quality of account keeping was found acceptable in the CHC/PHC
User Charges are being utilised adequately. However, the demand is more than
supply and a state decision to permit retention of full User Charges with the institution
is urgently required.
JSY payments in PHC/Sub Centres, albeit as per old rules and except for home
deliveries, is taking place.

Status of implementation of various schemes including training is at Annexure 5

Priority agreed actions to be taken:

The key area of concern is the delay in establishing the institutional mechanisms for
implementing the RCH II as well as the NRHM A Mission Director has not been appointed
and there is no movement pertaining to the recruitment of SPMU and DPMU staff.

The key recommendation is therefore to:

Appoint a Mission Director and recruit SPMU/DPMU staff on a priority basis and if
required through outsourcing to reputed institutions or development partners.
Concurrently the following can be initiated;
- Strengthen job descriptions including reporting relationships, indicators of
performance and relationship between Mission and technical directorates at state
and districts;
- Prepare plan for smooth induction of SPMU/DPMU staff by sensitization of
Directorate staff, District Collectors and PRIs;
- Develop a work plan with achievable outcomes on NRHM issues;
- Establish HRD systems for SPMU/DPMU staff including recruitment and
induction, continuous training and performance appraisal.

Additional recommendations are to:
Improve utilization of existing public and private sector resources through
comprehensive mapping of manpower, equipment and utilization through GIS and
existing PIS. Subsequently match needs with resources. This activity could be
carried out with TA;
Strengthen the district planning process through rationalizing criteria (i.e. population,
vulnerable groups) for allocation of funds to and within districts, provision of some
genuinely untied funds to enable districts to respond to local issues and have a wider
consultation processes (process consultants from the SPMU to assist in this
process);
Strengthen the MIS preparation process through the following:
- Integrate the MIS reporting system into the TORs of the PMUs

- 238 -
- Involve the stakeholders (data feeders & analytical users) in the development
process.
- Consider the ground realities of ensuring power supply and connectivity
- Ensure that the new systems help in reducing the work-load of the ANM, PHC,
CHC etc
- Have an IT Training Plan for the public health system personnel from the ANMs
upwards to not only get conversant with IT but on how local analytical needs can
be met to monitor performance
- Use IT media as a two-way channel to disseminate information on guidelines,
instructions and analysis of information;
Adapt and implement quality standards in public health and initiate accreditation of
public and private health institutions;
Explore further possibilities of public private partnerships to expand coverage of key
RCH services. For example, provision of laparoscopes to private sector trained
providers for provision of sterilization services;
Use NGO forum for dissemination of information to citizens and communities on GOI
flagship health and family welfare schemes;
Evolve a plan for multi-skilling of health service providers (especially anesthesia)
(doctors, paramedical staff);
Prepare a strategy and operational plan for intra communication (incl. PRI) as well
as. The state should develop a comprehensive strategy for BCC and also put a
robust monitoring and evaluation plan to ensure that the right messages are reaching
the target population groups for desired behavior change and that the
communications methods are cost effective. (Take into consideration GoI guidelines);
Fill up Questionnaire/Schedule for Assessment of Management Capacity of State
Govts. sent by GOI;
Sign MOU for Quality Assurance Pilot;
Enhance involvement of Community based institutions/organizations in community
monitoring;
Target the JSY better for improving institutional births as vast majority of the benefits
are accruing for home deliveries;
Finance Controllers role is more of a Controller than a Financial Manager Manager
(Finance) on the lines of JD (RCH) or JD (Training) is required;
Similarly in Districts only accounts personnel are visible Lack of any financial
management for funds to the tune of Rs.5 Crores per annum;
The delivery of Sanction orders/guidelines have to keep pace with e-transfer of funds
uploading them on web and faxing them is required. Disbursement of funds to
District should be delegated to lower functionaries for faster transfers transfers to
Districts are transfers within Govt. system and should not be equated with payments
outside the system;
Delayed Sub-Committee meetings generally lead to delayed transfers to Districts.
Similarly, in Districts more powers should be delegated to CMOs and levels below
him/her;
Initiate various training programmes in a time bound manner and ensure quality of
training.


- 239 -
Annexure 1

RCH Process Indicators: UP State
(Based on information provided by GOUP)


S.No. RCH Indicators Expected
Level of
Achievement
Level of
Achievement


Remarks
1 % of ANM positions
filled
80% 98.23% Sanctioned: 26156 (23656
regular + 2500 contractual)
In position as on Jan 1, 2007:
25695 (23576 regular + 2119
contractual)
Vacant: 465 (84 regular + 381
contractual)
2 a. % of districts
having full-time
programme manager
for RCH
b. Administrative &
financial powers
delegated
90% 100% DPMUs not been formed. In
the short-term, Dy. CMO RCH
appointed as nodal officer in
all 70 districts and powers
delegated.
3 % of sampled state
and district program
managers aware of
their responsibilities
80% 70% Orientation meetings &
workshops conducted
quarterly at state/district level.
SPMUs and DPMUs not been
formed.
4 % of sampled state
and district
programme
managers whose
performance was
reviewed during the
past six months
60% 95.7 % Quarterly review meetings of
the district program managers
are being conducted at the
state level and their
performance is being reviewed
regularly on the basis of their
physical and financial
performance. 67 out of 70
districts participate in these
performance review meetings.
Feedback is sent to the
concerning CMOs.
5 % of district not
having at least one
month stock of
a. Measles
Vaccine
b. OCP
c. Gloves

in the past six
months

<10% 0% No district has reported stock-
outs in past six months.
However, during the field-visit
during the RI session stock-out
of Measles vaccine was
observed at the sub-centre-
Neemgaon and FRU Palia in
Lakhimpur Kheri. According to
JD UIP, a particular vaccine
may be unavailable for a
session or so, but never for the
entire month. GOUP confirmed
that as per stock register &

- 240 -
S.No. RCH Indicators Expected
Level of
Achievement
Level of
Achievement


Remarks
indent forms received from the
district, none of them has
reported stock out for measles
in the past 6 months.
6 % of districts
reporting quarterly
financial performance
in time
80% 60% Instead of Oct 2006- Nov 15,
2006 was taken as cut off
date.
7 % of district plans
with specific activities
to reach vulnerable
communities
80% 80% As per GOUP, State Action
Plan was prepared in
consultation with
representatives from each
district. It includes special
urban slum plans to reach the
vulnerable communities by
holding MCH sessions in
outreach/difficult to reach
areas of 56 districts.
Remaining 14 districts have
been covered under SIP.
Urban slums covered in
NRHM PIP. Proposal of MMU
and Janani included in NRHM
PIP to address needs of
vulnerable population.

The team that visited
Lakhimpur Kheri could not
assess as the district plan was
not made available to the
team. However, the team that
visited Mirzapur observed that
the plan does not specifically
address the needs of the
vulnerable groups including
urban slums.

GoUP felt that the DAPs that
are now being developed will
be more focused towards
vulnerable communities.
8 % of sampled
outreach sessions
where guidelines for
AD Syringe used and
safe disposal
followed
80% 70% Guidelines issued. As per the
observers reports monitoring
the MCH sessions, 14 districts
out of the sampled 20 districts
were
following the guidelines.

AD syringes were found to be
in use by the review team. In

- 241 -
S.No. RCH Indicators Expected
Level of
Achievement
Level of
Achievement


Remarks
Mirzapur, the team did find
that patients were asked to
bring their own syringe and
that disposable syringes were
being recycled. Though the
state reported that hub-cutters
were provided and safe
disposal of needles is being
ensured, the review team did
not find evidence of the same.
9 % of sampled FRUs
following agreed IP
and health care
waste disposal
procedures
80% Data not
available
Awaiting GOI guidelines.
10 % of 24 hrs PHCs
conducting minimum
of 10 deliveries per
month
50% 54.4% As per MPR received from the
districts, 136 of the 250 units
providing 24 hrs delivery
services are performing more
than 10 deliveries per month.
11 % of CHCs upgraded
as FRUs offering 24
hr EMOC services
50% 28%
Sample of
Districts
visited by
review team:
0%
Only 14 out of 50 CHCs are
reporting EMOC services
(including caesarean section).
Not clear if these services are
being offered round the clock.
12 % of sampled health
facilities offering
RTI/STI services as
per the agreed
protocols
60% 71 % Only 50 CHCs are functional
as RTI/STI clinics (as against
planned level of 70). The staff
has received preliminary
training, guidelines from GOI,
and is regularly receiving
funds for consumables &
RTI/STI drugs.
13 M&E Triangulation Not being undertaken




- 242 -
Annexure 2

INTERMEDIATE INDICATORS: UP
(Filled by GoUP)

Reporting period: October December 2006 (except where specified as cumulative)

S.
No.
Indicator Target as
per PIP
(06-07)
Achievement Remarks Source
of data
Infrastructure
15. No. of PHCs upgraded to
provide 24X7 services
1
210 250 MIS
No. of health facilities upgraded to FRUs, fulfilling the minimal criteria as per the FRU
guidelines (at least the 3 critical criteria)
a. District Hospitals
1
MIS
b. Sub-Divisional Hospitals
1
MIS
c. CHCs
1
70 50 (Physical
Strengthening
completed)
MIS
16.
d. Others (pl. specify)
1
MIS
17. % of functional Sub-Centres
2
100 % 42.37 % MIS
Programme Management
18.
SPMU in place with 100 %
staff
3
SPMU proposal
finalized. Will
be in place
shortly.
Present RCH II
unit is looking
after the work.
MIS
19.
% DPMU staff in place
4
SPMU proposal
finalized. Will
be in place
shortly.
Dy. CMO RCH
II unit is looking
after the work.
MIS
Training
No. of personnel trained in IMNCI - 19 (State level trainers)
e. MOs
1
29
MIS
20.
f. ANMs
1
151
MIS
g. AWW
1
523
MIS
h. Others (pl. specify)
1
29 health
Supervisors +
16 Mukhya
sevika + 5
MPWs

MIS
No. of personnel trained in SBA None 21.
g. MOs
1

MIS

- 243 -
S.
No.
Indicator Target as
per PIP
(06-07)
Achievement Remarks Source
of data
h. ANMs
1

MIS
i. Staff nurse
1

MIS
No. of personnel trained in IUD insertion
g. MOs
1

MIS
h. ANMs
1

MIS
22.
i. Staff nurse
1

MIS
No. of MOs trained in
g. Life-saving anaesthesia
skills
1

Under Process
MIS
h. EMOC
1
16 LMOs have
been nominated
for Ist batch to
be started in
Feb,07.

MIS
23.
i. NSV
1
Dr. Patwaari
MIS
Maternal Health
24.
Proportion of ANC
registrations in first trimester
of pregnancy
5
70%
MIS
25.
% of planned RCH outreach
sessions held in the quarter
6
MIS
Child Health
26.
% of planned Immunization
sessions held in the quarter
6
621967 542112
87.16%
MIS


Family Planning
27.
% of planned Sterilization
camps held in the quarter
6

MIS
Adolescent Health
28.
Proportion of ANC
registrations in first trimester
of pregnancy for women <19
years of age
7

data not
available
MIS
Notes:

8. Please give cumulative figure to date since April 2005 in Target and Achievement
columns.
9. Numerator is no. of sub-centres with ANM present and working out of the facility.
Denominator is total no. of sub-centres.

- 244 -
10. SPMU is meant to have four core positions: State Programme Manager, State Data
Officer, State Finance Manager, and State Accounts Manager. Please only report
how many of these positions have been filled (as a percentage). Do not count other
consultants for this indicator.
11. Numerator is no. of DPMU positions filled. Denominator is no. of DPMU positions
required (no. of districts X 3 positions per district). The core DPMU positions District
Programme Manager, District Accounts Manager, and District Data Assistant.
12. Numerator is no. of pregnant women who registered for ANC in their first trimester of
pregnancy during the quarter. Denominator is total no. of pregnant women who
registered for ANC during the quarter (reference period October December 2006).
13. The denominator for each of these is no. of sessions/camps planned for the quarter
as per the workplan in the approved state PIP. Numerator is no. of pregnant women
<19 years who registered for ANC in their first trimester of pregnancy (during the
reference period). Denominator is total no. of pregnant women <19 years of age who
registered for ANC (during the reference period).

- 245 -

Annexure 3


Detailed observations based on the field visits.

Dedicated/committed staff is found at all levels and across locations;
Effective convergence between health and ICDS. At the PHC level regular monthly
meetings were being held between the health department and ICDS. At the sub-
centre level the ANM, AWW and ASHAs seem to be working well.;
Between JRM 2 and 3, improved availability of condoms, oral contraceptive pills and
Disposable Delivery Kits (DDKs) was observed. However, the team did observe
stock-outs of measles vaccine at the Routine Immunization session in Sub-centre
Neemgaon;
Sub-centre accounts for untied funds have been opened and funds have been
disbursed;
There was sub-optimal utilization of existing resources. The existing specialists were
not utilized appropriately as some of the supporting equipment and skills were
absent. For example the Gynecologist, Anesthetist and Surgeon at Gola PHC could
not function as no anesthesia or surgical equipment was in place. The District
Hospital Female in Lakhimpur Kheri uses ether for anesthesia as there is no Boyles
apparatus while the District Hospital Male has three sets of anesthesia equipment.
There were two Pediatricians placed at the Palia FRU and the services of both were
sub-optimally utilized;
The FRUs are not fully functional as per Government of India guidelines. During the
filed-visits it was observed that the staff was not fully aware on the details of
operationalization and management of these facilities;
While the coverage of key RCH services is inadequate, the quality of RCH services
also requires improvement. For example; women were immediately discharged after
caesarean section; we found poor case management of malnourished children;
proper care of newborn was not seen at any level and guidelines for anesthesia were
not followed- ether was being used for anesthesia;
The labor rooms in the 24X7 PHCs do not have adequate infrastructure. There is
lack of clean toilet, running water, receiving station, etc.;
A major area of concern is seemingly total lack of infection prevention and waste
management. No segregation of waste was seen, poor storage and disposal of
sharps and placenta and lack of mechanism for disposal at all levels;
The dissemination of standards and guidelines to field staff as well as the PRI needs
to be improved. For example, the district and field staff was not aware of the revised
JSY guidelines and the funds are being released as per earlier guidelines. JSY not
being implemented in District Hospital-Kheri as the guidelines are not clear to the
authorities. Also, PHC Neemgaon no benefit is being given to mothers for home
deliveries. Similarly, the awareness of Rogi Kalyan Samiti and the utilization of user
charges at the facility level were limited. Some confusion also exists with regard to
the use of untied funds at the sub-centre;
The district plans do not reflect local needs and the ownership of the plan among
stakeholders is variable and is compounded by frequent transfer of personnel. The
need for greater flexibility was also expressed by district officials;
The new MIES system is not yet in place;
The efforts to improve community awareness of various schemes need to be
undertaken and concerted BCC efforts are required to ensure that communities are
aware of correct practices, benefits of various schemes such as JSY and source
where services are available.


- 246 -
Annexure 4
Financial Management















Figure 1
















Figure 2
















Figure 3

Fund Flow Analysis
(As per Details Available till 15
th
Sept 2006)

UTTAR PRADESH:
(upto Sept.2006)
Rs. In Crores
299.73
43.54
0
50
100
150
200
250
300
350
Approved PIP Fund Utilized
15%
UTTAR PRADESH:
(upto Sept.2006)
Rs. In Crores
299.73
43.54
0
50
100
150
200
250
300
350
Approved PIP Fund Utilized
15%


Financial Analysis - MIRZAPUR
Rs. In Lakh
248 247
495
36
79
115
0
100
200
300
400
500
600
2005-06 2006-07 (upto Dec
31st)
Since Start of the
Prog.
Funds received Fund Utilized
14%
32%
23%
Financial Analysis - LAKHIMPUR-KHERI
Rs. In Lakh
193
256
449
49
102
152
0
50
100
150
200
250
300
350
400
450
500
2005-06 2006-07 (upto Dec
31st)
Since Start of the
Prog.
Funds received Fund Utilized
26%
40%
34%

- 247 -

Delay in deciding to disburse funds to Districts / Implementing
Units by Sub-Committee
Name of Activity 2005-06 2006-07
Strengthening of Training
institutes
1 Month 20 Days 1 Month 20 Days
EmOC
2 Month 20 Days 5 Months -?
Adequate balance available on 1/4/2006
No fund disbursed till Sept. 2006
Hiring of Contractual
Staff
1 Month 10 Days 5 Months -?
Adequate Balance available on 1/4/2006
No fund disbursed till Sept. 2006

Urban RCH 4 Months 4 Months 19 Days

24 Hours Delivery
Services
6 Months 16 Days 5 Months -?
Adequate Balance available on 1/4/2006
No fund disbursed till Sept. 2006

Adolescent Health 6 Months 5 Months-?
Adequate Balance available on 1/4/2006
No fund disbursed till Sept. 2006

RCH Camp 5 Months 5 Months -?
Adequate Balance available on 1/4/2006
No fund disbursed till Sept. 2006

Sterilization Camp 2 Months 5 Months-?
Adequate Balance available on 1/4/2006
No fund disbursed till Sept. 2006

JSY 4 Months 5 Months -?
Adequate Balance available on 1/4/2006
No fund disbursed till Sept. 2006


- 248 -
Annexure 5

Status of implementation of schemes

Maternal Health Status Remarks
Training for Skilled Birth Attendance Not started
Procurement of drug kits Orders placed for the
annual supply

Emergency Obstetric Care
- Implementation status for Skill up
gradation for management of obstetric
complications
- Training of doctors in EmOC and
Anaesthesia in states
- Planned but not
initiated as yet
- do -
SIFPSA is already
conducting training for
EmOC. To coordinate with
the state training efforts.
Guidelines for RTI/STI management
Not available
JSY Implementation
JSY card and
monitoring formats
developed and
disbursed. Funds
disbursed to districts
along with guidelines.
Upto 30.11.06, total
beneficiaries were
69,454
Varied understanding about
the scheme among different
officials. Need to generate
greater awareness about the
guidelines and purpose of
the scheme.
Issues identified in last JRM

CHILD HEALTH
Progress on IMNCI Initiated in one district
(Lalitpur); plan for
initiation in 17 districts
State Team has been trained
KGMC identified as the
nodal centre for the training
Home based New Born Care Plan to be initiated in
10 districts.
Will be implemented in 2
districts by SEARCH
Essential Newborn Care (Facility
based)
Needs assessment just
concluded.

Progress on Immunisation / vitamin A
supplementation
Continues to remain a
high focus activity.

Progress on ORT / Pneumonia (ARI)
Issues identified in the last JRM



- 249 -
FAMILY PLANNING
Upgradation of contraceptives
standards

QA guidelines dissemination
Providing safety insurance cover for
providers


ARSH
Follow up on Implementation Guide Guidelines and funds
disbursed. 14 pilot
districts identified.
State level workshop
conducted and first
district level meeting
conducted in 10
districts.

Follow up on training packages Training module under
development.
Existing modules including
GoI module on ARSH to be
reviewed


Infection Management and Environment Plan / IMEP
Policy framework document and
facility level operational guidelines
status
Guidelines sent to all
districts

Dissemination strategy agreed
including (a) communication to states
to integrate IMEP plans in RCH II PIP
and (b) separate communication to
mission directorates to link it to IPHS
Hub cutters have been
provided for safe
disposal of needles

Training plan for operationalizing
IMEP guidelines at facility level
finalized
Supervisors/monitors
instructed to monitor
safe disposal during
their supervisory visits


Public Private Partnership
Special plans included in NRHM PIP.
Proposal on lines of Janani included
Action to be initiated

NGOs
2. MNGOs, FNGOs funded and
number of proposals sanctioned
3. Capacity building plans
4. Assessment of NGO scheme
28 NGOs finalized &
funds disbursed; 27
MNGOs finalized in 29
districts



- 250 -
Status of various training Programmes

Skilled Birth Attendance training training calendar in place but funds awaited for want of
a designated person to manage this training.

Comprehensive Emergency Obstetric Care Four Medical Colleges have been identified
to conduct comprehensive emergency obstetric care training. However, stress on basic
emergency obstetric care is also required to have all medical officers trained to be able to
provide basic obstetric care. State must set a date for initiating these training programmes.

Multi-skilling of doctors - Plan for training Medical Officers on Anesthesia skills has been
developed and Kanpur Medical College has been identified for conducting Training of
trainers. Training is yet to start.

Child Health - For Integrated Management of Neonatal and Childhood Illnesses (IMNCI), a
state training team of 19 persons trained at the national level is in place. The King Georges
Medical College Heads of Departments of Paediatrics and PSM shall be the state nodal
centre for IMNCI training. Two district Hospitals with a high case load, committed personnel
and good accessibility have been identified to serve as additional training centres for IMNCI
(Balram Hospital and Civil Hospital). Seventeen districts have been identified for IMNCI
implementation, one from each division. Additional districts, Barapankhi and Kannuaj have
been identified as the districts for Home Based Newborn Care implementation. The planning
meeting for HBNC implementation shall take place on 23-24
th
January 2007. Infant and
young Child Feeding guidelines are being implemented and training for this has been carried
out in 54 districts with support from UNICEF and Breastfeeding Promotion Network of India
(BPNI).

Family Planning As per the Directorate of Family Welfare, no training planned or
conducted for female sterilization, male sterilization / NSV or IUD. SIFPSA is conducting
training for Medical Officers in NSV for 33 districts. Urology department of KGMU, Lucknow
has been identified as a static training centre for NSV for induction and refresher training for
NSV trainers. SIFPSA is also conducting laparoscopic and abdominal sterilization training
through Lucknow, Agra, Kanpur and Meerut Medical Colleges for all districts of UP. Funding
is available till 2008 through SIFPSA.





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RCH II: FINDINGS OF 3
rd
JRM

WEST BENGAL

West Bengal has shown initiative in improving implementation on the ground as was
suggested in the 2
nd
JRM. Capacity building of technical staff to ensure improved quality of
services in the facilities needs to be fast tracked. Orientation of management unit staff is a
priority. DHAP needs to be completed at the earliest by March 2007. Steps need to be taken
to operationalize PHCs at the earliest. JSY needs to be promoted through extensive IEC.
Greater focus on fund utilization is necessary.

Financial progress
FY 05-06 FY 06-07
Allocation Rs. 95.50 Crores Rs. 113.80 Crores
Release Rs. 59.83 Crores
Rs. 30.66 Crores
(till Sept. 06)
Reported Expenditure
Rs.3.16 Crores
Rs. 2.78 Crores
(till Sept. 06)
Expenditure/ Release 5% 9%
Expenditure/ Allocation 3% 2%

Component wise observations and suggested action points are as follows:

JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
MATERNAL HEALTH
IEC should be strengthened
to provide more information
on RTI/STI
Try to look into the issue of
early marriage at
Panchayat level
RTI and STI interventions
should start from village
level
Village level IEC camps
held as family health
awareness camps







Organize village
health days in
coordination with
AWWs
ASHA for NRHM has been
approved for 5 blocks rest
of ASHA may be put under
RCH II as health workers
13613 ASHAs to be placed
in 80 underdeveloped
blocks

Train ASHAs on a
priority basis
74/342 PHC functioning as
24X7 facility
10148/10356 ANM
positions filled
Ensure that at every
block has a functional
facility.

56442 institutional
deliveries registered under
JSY
Health Supervisor posted in
GPs to report maternal and
child deaths
12, 925 medical outreach
camps held.
Promote JSY through
extensive specific IEC

- 252 -
JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
CHILD HEALTH
IMNCI training started in
Purulia
4480 TBAs trained in home
based care
Special immunization week
microplanning undertaken
with active involvement of
PRIs, AWWs and SHGs
Vitamin A supplementation
and routine immunization
programs implemented in
collaboration with DWCD,
PRIs and SHGs

FAMILY PLANNING
Regional level meetings
held to disseminate
guidelines on sterilization
Lap litigation, minilap and
NSV training organized for
MOs, surgeons, and nurses

GOVERNANCE
Recruitment of DPMU staff
completed in 18 districts
Complete DHAP of
the prioritized 6
districts by March
2007.
Need to orient DPMU
staff and involve them
in DHAP preparation
process
TRAINING/ IEC/ NGO INVOLVEMENT
First batch of anesthesia
training for 21 MOs
completed


NGOs rendering services in
7 remote blocks of South
Parganas
Unserved and underserved
areas identified in 4
districts
Utilize services of
NGOs for training of
ASHAs
INNOVATIONS
Mapping of private facilities
completed in 11 selected
districts under the
Ayushmati scheme
334 ambulances procured
and providing services in
collaboration with NGOs
and CBOs


- 253 -
JRM 2 RECOMMENDATIONS ACTION TAKEN & FURTHER
ACHIEVEMENTS
SUGGESTED ACTIONS
OTHERS
State to systematically
provide documentary
evidence for achievement
of core 13 indicators as
specified in Enclosure 4 of
the JRM Process Manual.

May partner with The Red
Cross for the requirement
of blood banks.



Progress on 13 identified process indicators:

S.No. RCH Indicator Level of
Achievement
1 % of ANM positions filled 98%
2 a. % of districts having full time programme manager for RCH
b. Administrative and financial powers delegated
100%
3 % of sampled state and district programme managers aware
of their responsibilities
100%
4 % of sampled state and district programme managers whose
performance was reviewed during the past six months
100%
5 % of district not having one month stock of
a. Measles vaccine
b. OCP
c. Gloves
Nil
6 % of districts reporting quarterly financial performance in time 70%
7 % of district plans with specific activities to reach vulnerable
communities
60%
8 % of sampled outreach sessions where guidelines for AD
syringe use and safe disposal followed
---
9 % of sampled FRUs following agreed IP and health care
waste disposal procedures
45 facilities

10 % of 24 hrs PHCs conducting minimum of 10 deliveries per
month
74 out of 342 PHCs
functional 24x7.

11 % of CHCs upgraded as FRUs offering 24 hr EmOC services 27 FRUs to be
operationalised by
Mar 07
12 % of sampled health facilities offering RTI/ STI services as
per the agreed protocols
Facilities available in
all DH, all SDH and
25 out of 95 RHs
13 M & E Triangulation