Reproductive & Child Health Programme Phase II

2nd Joint Review Mission

September 25 October 11, 2006

AIDE MEMOIRE
October 2006

DONOR COORDINATION DIVISION

MINISTRY OF HEALTH & FAMILY WELFARE

GOVERNMENT OF INDIA

CONTENTS S.NO . I. II. III. IV. INTRODUCTION EXECUTIVE SUMMARY PROGRESS TOWARDS PROGRAM OBJECTIVES IMPLEMENTATION PROGRESS a. Access and Equity b. MOHFW Program Management c. Maternal Health d. Child Health e. Family Planning f. Training g. Innovations in Service Delivery h. Demand Creation i. Monitoring and Evaluation j. Procurement k. Financial Management l. Convergence V. AGREED KEY ACTIONS TO BE COMPLETED BY NEXT JRM ANNEXES ANNEX NO. 1 2 3 4 5 6 7 JRM II PROCESS MANUAL RCH FLEXI POOL (PART A) FUND RELEASED AND EXPENDITURE METHODOLOGY FOR RANKING OF STATES IMPLEMENTATION STATUS OF PRIORITY ACTIONS AGREED TO IN THE FIRST JRM PRIORITY ACTIONS AGREED TO IN THE SECOND JRM STATE REPORTS MOHFW PROGRAMME DIVISION REPORTS 25 55 56 58 65 69 177 PAGE NO. 1 1 5 6 6 8 9 11 12 13 14 15 16 17 19 21 22

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

ABBREVIATIONS ANM ANMTC ARI ARSH ASHA AWW AYUSH BCC BPL CBO CHC CTI CTP DAP DC DC Division DFID DHFW DH DHO DHRC DHS DLHS DP DPMU DWCD EAG EC EmOC EPW FMG FMR FNGO FOGSI FP FRU GMP GoI HP HR HRD J&K ICDS IEC IMEP IMNCI IMR IPHS ISM IUD JRM JSY : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : Auxiliary Nurse and Midwife ANM Training Centre Acute Respiratory Infection Adolescent Reproductive and Sexual Health Accredited Social Health Activist Anganwadi Worker Ayurveda, Yoga, Unani, Siddha and Homeopathy Behaviour Change Communication Below Poverty Line Community Based Organisation Community Health Centre Collaborating Training Institute Comprehensive Training Plan District Action Plan District Collector Donor Coordination Division Department For International Development (United Kingdom) Department of Health and Family Welfare District Hospital District Health Officer District Health Resource Centre District Health Society District Level Household Survey Development Partner District Programme Management Unit Department of Women and Child Development Empowered Action Group Emergency Contraception Emergency Obstetric Care Empowered Procurement Wing Finance Management Group (MOHFW) Finance Management Report Field NGO Federation of Obstetric and Gynaecological Societies of India Family Planning First Referral Unit Good Management Practices Government of India Himachal Pradesh Human Resource Human Resource Development Jammu & Kashmir Integrated Child Development Scheme Information, Education, Communication Infection Management and Environment Plan Integrated Management of Neonatal and Childhood Illness Infant Mortality Rate Indian Public Health Standards Indian System of Medicine Intra Uterine Device Joint Review Mission Janani Suraksha / Suvidha Yojna

ii

LHV M&E MDG MIES MMR MNGO MO MoHFW MOU MPW MTP NERRC NFHS NGO NHSRC NIHFW NRHM PHC PIP PMSG PMU PMSU PNDT PPP PRI RCH RET RKS RRC RTI SBA SC&ST SHC SHS SIHFW SPMU SHSRC STI TFR TNMSC TOR TOT UC UNFPA UNICEF UP USAID UT WHO

: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :

Lady Health Visitor Monitoring and Evaluation Millennium Development Goal Monitoring Information and Evaluation System Maternal Mortality rate Mother NGO Medical Officer Ministry of Health and Family Welfare Memorandum of Understanding Multipurpose Worker Medical Termination of Pregnancy North East Regional Resource Centre National Family Health Survey Non Government Organisation National Health Systems Resource Centre National Institute of Health and Family Welfare National Rural Health Mission Primary Health Centre Programme Implementation Plan Programme Management Support Group Programme Management Unit Programme Management Support Unit Pre Natal Diagnostic Techniques Public Private Partnership Panchayati Raj Institutions Reproductive and Child Health Regional Evaluation Team Rogi Kalyan Samiti Regional Resource Centre Reproductive Tract Infection Skilled Birth Attendant Schedule Castes and Scheduled Tribes Sub Health Centre State Health Society State Institute of Health and family Welfare State Programme Management Unit State Health Systems Resource Centre Sexually Transmitted Infection Total Fertility Rate Tamil Nadu Medical Services Corporation Terms of Reference Training of Trainers Utilisation Certificate United Nations Population Fund United Nations Childrens Fund Uttar Pradesh United States Agency for International Development Union Territory World Health Organization

iii

REPRODUCTIVE AND CHILD HEALTH PROGRAM, PHASE II SECOND JOINT REVIEW MISSION: SEPTEMBER 25-OCTOBER 11, 2006 AIDE MEMOIRE I. INTRODUCTION 1. The second Joint Review Mission (JRM) of the Reproductive and Child Health Program, Phase II (RCH II) assessed progress made since first JRM held in January 2006 and identified key implementation bottlenecks. Agreements were reached to enhance implementation pace 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 that ensure quality of care, and strengthen results measurement. In April 2005, Government of India launched the National Rural Health Mission (NRHM). The RCH II program has become an important and integral component of NRHM as several initiatives envisaged under the NRHM: Accredited Social and Health Activists (ASHAs) for community mobilization, the Janani Surakha Yojana (JSY) a voucher scheme to promote safe deliveries and untied funds to health facilities to make them functional, directly contribute to outcomes expected of the RCH-II program. 2. The JRM held during September 25 to October 11, 2006 was led by Ministry of Health & Family Welfare (MOHFW) and joined by state representatives and all Development Partners supporting RCH II program. Detailed field visits were made to 18 program focus states 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 to Annex 1 for the JRM Process Manual). This aide-memoire summarizes the findings of the JRM and agreed actions for accelerating implementation. II. EXECUTIVE SUMMARY 3. The JRM findings are based on the observations during field visits, interactions with program officials, staff and community groups, and information shared during presentations and discussions with program divisions. JRM noted that institutional arrangements for implementation of RCH under the overall umbrella of NRHM is more or less complete in all States. More than 2 lakh ASHAs are in place. Management support for NRHM/RCH is more or less put in place at State and district levels. The JRM rates overall progress made by finance, procurement, NGO, Training and IEC divisions of MOHFW satisfactory. The other program divisions need to accelerate implementation as agreed in the National Program Implementation Plan (NPIP). While the MOHFW has clearly prioritised the 18 NRHM focus states for enhanced attention, the progress made in program implementation in these states is mixed. Among the larger states Bihar, Gujarat, Chhattisgarh, West Bengal, Madhya Pradesh, Andhra Pradesh, and Orissa have started some promising initiatives to make selected facilities operational while Uttar Pradesh continues to lag behind. States have made progress in the preparation of district action plans and released funds to districts. However the prioritisation of the worst off districts for additional allocation of resources to match the needs reflected is yet to be addressed. In light of village and district health action plans envisaged under NRHM, capacities for bottom-up planning require strengthening at district and sub district levels. A major concern is lack of disaggregated performance data to show improved use of RCH services by the poorest and most vulnerable populations, an important paradigm shift envisaged in RCH II. 4. MOHFW, during the past nine months has made progress on the following:

-1-

MOHFW has supported setting-up program management units at state and district levels and had several rounds of consultations with states to ensure adequate focus on results as reflected in the Memoranda of Understanding. Strengthening of the fiduciary systems. Systems for efficient transfer of funds to states and reporting expenditure have been established. Ensuring timely release of funds to states following the equity based formula. MOHFW was able to promptly respond to emerging needs of the focus states by making over Rs. 100 Crore above the budgeted allocations in 2005-06. Creation of integrated purchase committee, which is expected to streamline clearance processes in MOHFW and an advance order for vaccines. The international consultants have carried out preliminary review of procurement and logistic capacities at MOHFW and some states have started preparing plans for capacity building. Guidelines for effective implementation of Good Manufacturing Practices have been prepared and first round of market surveys have been completed. Evolving policies and technical guidelines in line with the agreed core program principles. Guidelines on IMNCI and ARSH services have been developed and disseminated to the States. For the first time, user-friendly modules for facility based Infection Management and Environment Plan (IMEP) have been drafted. National strategies for training and Behaviour Change Communication have been finalized and shared with states. The new strategy of decentralized selection and oversight of NGOs supported by capacity building through 11 regional resource centres is progressing well. Ensured increased focus on the quality of contraceptive services and products through development and dissemination of quality assurance manuals. MOHFW has also facilitated multi-skill trainings for graduate doctors in highfocus states. MOHFW also played a proactive role in encouraging the focus states to improve delivery of routine immunization services. Tools for monitoring service quality also have been developed and will be piloted in 6 states. The MOHFW undertakes quarterly reviews of the programme for all states and UTs, which serve as interactive forums for discussing bottlenecks and their solutions in programme implementations.

5. The MOHFW has put in serious efforts in preparing states for establishing institutional arrangements as envisaged in RCH-II. Inspite of this, the JRM observed the following areas of concern: There have been delays in establishing the agreed arrangements for measuring results, especially disaggregated data on use of two essential RCH services indicators by the vulnerable groups which is an important criterion agreed for performance based financing to states from the second year of the program. Several actions to improve child health are still at the stage of policy formulation, which need to be translated into implementation guidelines soon. Accelerated implementation of child health interventions, especially new born care is critical for India to achieve MDG.

-2-

Less attention is being given to ARI and Diarrhoea management in non-IMNCI districts. With the time required for scaling-up of IMNCI the interim actions on home based newborn care need to be given urgent attention. Unmet need for both terminal and spacing methods still remains. On-site support to states has to increase. There has also been a delay in establishing the program management support group and making National Health Systems Resource Centre (NHSRC) fully functional. In light of the expanded NGO program, it is important to objectively assess their performance.

6. Acute shortages and stock outs of essential RCH pharmaceuticals and supplies were noted during the field visits as states could not procure them despite MOHFWs emphasis on the decentralization of this function. The Ministry has agreed to appoint a procurement agent or an UN agency for supplying essential RCH pharmaceuticals and supplies as an interim measure and this should be complemented by actions to strengthen procurement and logistics capacities of states in line of Tamil Nadu Medical Services Corporation and Govt. of NCT of Delhi. Further, a business plan for the Empowered Procurement Wing (EPW) clarifying its status and scope of work is necessary. Attention is also required to complete the assessment of quality and quantity of pharmaceuticals and capacity building of drug inspectors in effective implementation of good manufacturing practices as per the agreed schedule. 7. During the State review of the programme, the JRM observed: Thirty states have signed the Memoranda of Understanding with MOHFW, with the exception of UP, Karnataka, Delhi, Lakshadweep and Andaman & Nicobar Island. State and District Program Management Units have been set-up by all the erstwhile EAG states except UP. Thirty-four states have established an integrated health and family welfare society. Bihar has started to use this mechanism of Integrated Health & Family Welfare Society for more efficient delivery of health services. The paradigm shift in Bihar is quite evident during the field visits. The state has strategically focused on making few facilities operational by rationalizing staff and monitoring their performance on a daily basis, conceived and rapidly implemented public private partnerships to provide diagnostic and mobile services to inaccessible areas, and implemented a simple and effective procurement policy that ensured supply of limited number of essential drugs. Increased use of public health facilities is evident during the field visits. Chhattisgarh and Orissa reported improvements in immunization coverage mainly through community based workers, filling-up of ANM posts and more intense monitoring and supportive supervision. Among the other states, Gujarat and West Bengal reported reforms to improve service delivery. Gujarat started a major initiative to enhance private participation in the delivery of safe motherhood services in districts with poor access and initial assessments show encouraging results. West Bengal has created a public health administration cadre and both Gujarat and West Bengal have started recruiting professional managers to run health facilities/services. MOHFW will organize workshops between two JRMs planned in a year to disseminate such best practices to other states.
-3-

The mother NGO scheme is now expanded to 404 districts and implementation of Integrated Management of Childhood Illness (IMNCI) has started in 75 districts.

8. The expenditure reported by states for FY 2005-06 is around 44% of GOI releases. However, there was wide variation in use of funds across states with Orissa reporting a high (90%) expenditure and states like Bihar and Uttar Pradesh with 15% & 28% respectively (refer Annex 2). Considering the changes in funds flow and financial management arrangements, this level of expenditure in the first year of the program is satisfactory. 9. The JRM examined the relationship of the improved programme performance vis--vis the vulnerable population. Among 35 states that participated in the review, only Gujarat reported disaggregated data on use of RCH services by Scheduled Castes and Tribes and Karnataka has informed the availability of such data. As most states could not report data on all 13 process indicators, a meaningful conclusion could not be drawn. However, the data on limited set of process indicators shared by states, observations during field visits, monitoring of immunization sessions suggest improved access to routine immunization services and availability of Auxiliary Nurse Midwifes (ANM) and vaccines at session sites. 10. Discussions with the state and district program managers and facility staff suggest incomplete understanding of program guidelines affecting the implementation of the programme. The integration of the new program management units with the health department is slow possibly due to lack of clarity regarding their respective roles and responsibilities and high turn over of consultants. Field visits highlighted acute shortage of essential RCH pharmaceuticals and staff, especially nurses, lady medical officers and specialists. Most states such as NE States are filling the sanctioned posts through contractual appointment rather than posting regular staff. Slow progress in multi-skill training of medical officers is hindering in making the FRUs operational as well as in the scaling-up of safe motherhood interventions. There is a need for clear plans by states to make facilities operational, focusing first on those requiring minimal additional inputs for full operationalisation, and those serving the neediest populations. KEY OBSERVATIONS OF THE SECRETARY HEALTH AND FAMILY WELFARE AT THE WRAP UP SESSION OF JRM, 11 OCTOBER 2006 (a) Develop District Health Resource Centres (DHRCs) in progression with NHSRC and SHSRC, for coordinating all activities at district level and to serve as a pro-active think tank and a repository / hub of technical skills (nurses, data managers) and stakeholders (PPP) with appropriate linkages to the grass root service provider (ASHA). (b) Enhance focus on nurses and paramedics. Ensure standardised training and their empowerment, to facilitate technically sound, bottoms up health planning with adequate support from higher levels. A specialized nursing cadre can improve the quality and delivery of primary health care. (c) Focus on block level planning and on optimising resources at that level to prepare the district plans initially. Subsequently initiate village level planning. (d) Encourage independent and innovative approaches to planning and implementation as well as the quality aspects of capacity building. World Bank Institute was requested to participate actively in this context through the proposed Capacity Development Project.

(e) Enhance / set up the traditional inspection and supervision mechanisms which used
to work more effectively. State and GOI Officers to undertake field visits at regular
-4-

intervals and submit structured reports. These reports may be further analysed to iron out issues in implementation and planning or used pro- actively for dissemination on best practices, etc. (f) Strengthen the availability of health data to monitor the programme more efficiently. A situational analysis may be made quickly to understand the weaknesses in the flow of information and where investments are needed. Re-activate the M&E Working Group. Establish a system that collects data on a routine basis, in e-mode from the sub district level and also facilitates data analysis such that the routine reporting system is preferred over survey based data results. Further IDSP may be re-looked at, so that it becomes a part of holistic health data system.

(g) The RCH-II Programme needs to take cognisance of the NRHM Implementation Framework particularly the availability of a fully trained ASHA at the village level. (h) The Ministry has been delegated enhanced administrative and financial powers by the GoI under NRHM to expedite and facilitate decision-making, which will strengthen implementation of all components of NRHM including RCH -II. (i) Special initiatives are required for the NE States in the context of its unique geographical and socio-political characteristics of the region. (j) Intra-communication at all levels is weak. There is a need to focus on this by having a calendar of events to map the activity and also by providing information through exchange of letters, posters, CDs etc to the officers and staff at all levels (k) There is a need to appoint a HR expert or an agency to facilitate good HR practices in states. (l) Convergence of HIV/AIDS program with RCH-II needs to be explored to a greater degree (m) There is a need for simplification of the entire health care system. (n) Based on suggestions of the UNFPA, a thematic approach may be adopted for the next JRM. (o) Develop certified distance learning courses / programs for the Health Sector thereby creating a pool of qualified health professionals (especially in non technical areas like Accounting, Management and MIS) and opportunities for career progression resulting in enhanced motivation and sustainability of manpower. III. PROGRESS TOWARDS PROGRAM OBJECTIVES: 11. The third National Family Health Survey (NFHS 3) carried out in 2005 will provide state level data on key outcome indicators [(a) % eligible couples using modern contraceptive methods, (b) % deliveries conducted by skilled providers and in institutions, (c) % 12-23 months children fully immunized, and (d) % mothers and children visited within one week of delivery] by next JRM scheduled in February 2007. District household surveys planned in FY 2007 will provide independent disaggregated district level data on agreed key outcome indicators by April 2008. Cluster surveys carried out by UNICEF and session monitoring in EAG states suggest improvements in routine immunization coverage. 55% of children in age group 12-23months (19% in Bihar to 90% in HP) were fully immunized. However India could not reach polio free status by 2006. As of September 30, 2006 the country has reported 352 cases out of which 312 are from the state of Uttar Pradesh alone. As indicated above, inadequate reporting of progress in process indicators, and triangulation of the data is a major cause of concern and requires urgent attention by the program steering committee. However, based on the available data on a sub set of process indicators an effort has been made to rank the states in the table on the following page (refer Annex 3 for details of

-5-

methodology adopted for ranking state performance). 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. Ranking of high focus states based on available Process Indicators
State % of 24 hr PHCs conducting minimum 10 deliveries per month (50%) 1 0.5 0 1 0.5 0.5 0 0 0 1 0 0 0 0 0 0 0 0 0-29%=0; 30-49%=0.5; >49%=1; weight is 2 % DPMU in place & trained (50%) * 1 1 1 0 1 0 1 1 0 0 0 0 0 0 0 0 0 0 0-49%=0; >49%=1; weight is 2 % DAPs (50%) % ANMs in position (80%) 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 1 0 0-79%=0; >79%=1; weight is 2 5. % Fund Utilization (30%) Overall Score Rank Grade

MP Orissa Uttaranchal Tripura Jharkhand Assam Rajasthan Chhattisgarh Himachal Pradesh UP Arunachal Pradesh Manipur Sikkim Bihar Meghalaya Mizoram Nagaland J& K

1 1 1 1 0 1 1 1 1 0 0 1 0 0 0 0 0 0 0-49%=0; >49%=1; weight is 2

1 1 1 1 1 1 1 1 1 0 1 0 1 0 0 1 0 0 0-29%=0; >29%=1; weight is 2

10 9 8 8 7 7 6 6 6 4 4 4 4 2 2 2 2 0

1 2 3 3 4 4 5 5 5 6 6 6 6 7 7 7 7 8

A A B A B B B B B C C C C D D D D D 9-10=A 6-8 = B 4-5 = C 0-3 =D

* This ranking is based on limited set of data reported by states during the review. Eventually the ranking will be more comprehensive and based on full set of indicators agreed for the program. A score of 0 is also given where information on the particular indicator is not available.

IV. IMPLEMENTATION PROGRESS IV. a. Access and Equity 12. Increasing access to mainstream, basic health service by the poorest communities with the worst health indicators is one of the fundamental principles of RCH II and this has been articulated in the vulnerable groups health plan. The JRM found that this aim is not widely understood. It needs to be disseminated to all levels of the health service and this should be a priority task for the IEC Division and program managers at different levels. As steps to

-6-

provide access to care to the vulnerable population, the states are conducting health camps, service delivery through mobile vans, and boats and also specific interventions for the tribal population and urban poor. ASHAs should continue to be recruited from underserved habitations and communities with poor health and nutrition indicators. Urban Slum/ Tribal Health 13. Urban Health Division has developed a Project Implementation Plan (PIP) for Vulnerable Groups, which covers (a) urban slum population (b) tribal population living in notified tribal areas and (c) other vulnerable groups including SCs/STs living outside urban slums and notified tribal areas. The PIP for Vulnerable Groups has been circulated, as a part of RCH II document, to all the States/UT Governments, with a request to prepare individual urban health proposals and to include the same in the State PIPs under RCH-II. 14. Under this programme, out door services viz. antenatal Care, post natal care, referral for institutional deliveries, immunization service, FW services including IUD, RTI/STI, supply of contraceptives, ORS and services under various Disease Control Program would be provided at 1st Tier i.e. Urban Health Centre level. Indoor services, including institutional delivery, Basic Obstetric Care, terminal methods of contraception and curative services for RTI/STI etc. would be provided at 2nd Tier level. 15. States like M.P., Jharkhand, Rajasthan, Maharashtra, Uttaranchal and Bihar had held State level Urban Health Consultation workshops with a view to sensitise their officers. The Government of India has nominated Urban Health Resource Centre of USAID as Technical Support Agency for States/UTs to seek technical assistance, if required. 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. They should be embedded within an overarching and holistic long-term strategy defining service package, follow-up mechanisms and partner management. (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) Very low expenditure has been reported on the Urban/Tribal Health components under the RCH-II PIPs for 2006-07. Agreed Actions: (a) By November 2006, the states should in initiate wider dissemination of the equity aims of RCH2 to PRIs, NGOs and CBOs working with SC/ST populations. This will need to be maintained over the next year. (b) MOHFW will immediately communicate relaxation of educational norms and modification of ASHA training manuals for less literate individuals. (c) 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. (d) The State and district plans for 2007-08 should ensure the following:
-7-

 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. IV. b. MOHFW Program Management: 16. GoI has approved the establishment of the National Health Systems Resource Centre (NHSRC) as an autonomous society. In the interim a secretariat has been established with support from USAID and UNFPA/DFID funds and the MOU and byelaws for the society have been drawn up. The Executive Director is expected to be appointed by October 2006 and it has been decided to physically locate the centre within the National Institute of Health & Family Welfare (NIHFW). In the meantime, the Program Management Support Group (PMSG) has also been set up. Timely provision of technical assistance and support to states and districts is expected to be enhanced with the establishment of these two bodies. 17. Memoranda of Understanding with the MOHFW for implementation of the RCH II program state PIP have been signed by all States except Karnataka, UP, Delhi, Lakshadweep, and Andaman & Nicobar. Recognizing that there is insufficient clarity on the roles of the state and district program management units and their functional linkages with the state health department organization structure. MOHFW retained a consulting firm to review institutional arrangements in the 8 erstwhile EAG states and develop appropriate human resource policy based on review findings and consultation with states. 18. An Organisational review of the MOHFW was undertaken by AF Fergusons. This also included a review of the regional offices and the CGHS. The Ministry is in the process of establishing a Human Resource Cell to take up the recommendations of the report, and also to address the need for various trainings/capacity building, and to initiate actions on filling up the vacant positions of the Ministry. This Cell is expected to be functional by November 2006. Areas of Concern: (a) The implementation on the Human Resource Manual, prepared after the human resource review conducted recently by the States, has been slow. As a result, the clarity on the roles of the state and district program management units, and their bonding with and positioning in the states health department, is still required. (b) High attrition of staff is becoming an area of concern, especially accountants. This requires closer monitoring and interaction by MOHFW to help states to implement appropriate remedial measures that are locally relevant to attract and retain consultants.

-8-

(c) Need for 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. (d) Enhanced facilitation required from MOHFW to clarify major shift envisaged in RCH II program management to states, especially for North Eastern states that received less inputs during program development leading to insufficient knowledge and lack of clarity of procedures. PMU recruitment in some NE States is not in accordance with the guidelines. Agreed Actions: (a) By December 31, 2006 MOHFW will have series of discussions with states to ensure adequate understanding of the roles and responsibilities of the program management structures and their relationship and binding with the department of health at the state and districts. (b) By December 31, 2006 the planned HRD strategy review for state and district program management units in HP, J&K and Assam will be completed. (c) By April 2007, 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, will be in place. IV. c. Maternal Health 19. Maternal Health Division has developed comprehensive technical guidelines for Skilled Birth Attendants, management of common obstetric complications, 24 hours service provision through PHCs and multi skills training of doctors with particular emphasis on life saving skills in obstetric anaesthesia. These guidelines have also been disseminated to all states. Most states have adapted the national guidelines for the Janani Suraskhsha Yojana (JSY). Initial trends indicate an increase in number of institutional deliveries in the EAG states such as MP and Orissa. However, changes made in guidelines with a view to make them simple and responsive over the past year has led to confusion at the service delivery levels. The recommendation of the last JRM, for developing a set of Frequently Asked Questions with answers were circulated to the States, and future modifications will also be disseminated to all stakeholders. 20. Maternal health division has developed guidelines for management of common obstetric complications for medical officers. This is a part of the curriculum for training of MBBS doctors in EmOC by FOGSI. Multi skill training of doctors in anaesthesia and EmOC is the important component for operationalising the FRUs. The planned training load is substantial to make these facilities operational in accordance with the agreed guidelines. The MOHFW and the states will need to ensure that the numbers of master training centres and the master trainers are increased to complete the required training load. 21. Over 1700 CHCs and over 5000 PHCs have been identified to be made operational as FRUs and 24-hour service delivery PHCs respectively. However, during the field visits the states seemed to be implementing these initiatives in a very mechanical manner and focusing only at inputs. There is urgent need for better coordination of training, facility upgradation, and staff deployment to ensure increase in institutional deliveries. With most states initiating the first round of trainings for health workers in Skilled Birth Attendance (SBA), finalizing facilitators guide and learners guide for this training will be a priority. Procurement of essential supplies such as Tab Misoprostol, Inj Magnesium Sulphate, Inj Oxytocin should also be done in tandem, by the States/Procurement Division, so that the trainees have the facilities to practice the newly acquired skills in adherence with guidelines.

-9-

22. Madhya Pradesh and a few other States have started implementing multi-skill training program for doctors. Close monitoring of these training programs by the MOHFW will be needed, especially to assess the skills and incorporate any mid course corrections as required. 23. Some states are implementing innovative approaches to partner with the private sector for improving access to safe motherhood services including referral transport for pregnant women. These schemes need to be evaluated early on by MOHFW and encourage other states to replicate successful models. 24. Complications from unsafe abortion continue to be important causes of maternal morbidity and mortality in India. However progress has been slow in making MVA kits available at the peripheral facilities, training of doctors to enhance access to safe post abortion services. Areas of Concern: (a) Uneven availability and understanding of the technical guidelines was seen during the state visits resulting in variations in implementation. In states where skill training of providers has been started, the trainees are not always from the facilities identified for up-gradation. This will hinder the provision of planned services from those facilities. While over 1700 FRUs have been reported to be made operational, during field visits it was observed that most of these facilities do not have the full complement of inputs (trained staff, equipment, drugs and blood banks etc) and in effect only basic obstetric care is being provided by these facilities in most places. ANMs are expected to function as SBAs and conduct normal deliveries. However, they are currently not all in place and also are not adequately trained. There is no standardized training material available for emergency obstetric care training facilitated by FOGSI.

(b)

(c) (d)

Agreed Actions: (a) By January 2007 the NHSRC will ensure provision of a group of 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 states in preparing plans for monitoring training quality and post training follow ups for highly skilled clinical trainings; By January 2007national protocols for management of RTIs/STIs along with training guidelines and material will be finalized and shared with states through workshops and state visits. By December 2006 the Maternal Health division will 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 EAG states. These workshops will be 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. By December 2006 all focus states will prepare IEC plans to create increased awareness about the JSY, especially among members of local bodies and community based organizations who in turn will sensitise the communities about JSY. 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
- 10 -

(b) (c)

(d)

(e)

SBA in pre-service training of ANMs and SNs in consultation with Advisor (Nursing) and Training Division. IV. d. Child Health: 25. The IMNCI Guidelines have been finalized and disseminated. About 75 districts have been identified for IMNCI implementation till June 2006, out of which 33 districts are already at an advanced stage of implementation. The remaining 42 districts are in the initial phase or are yet to start training. More than 14,000 workers including Anganwadi Workers (75%) and health staff (25%) have been trained in IMNCI across the country. The Department of Women and Child has made a policy decision to include IMNCI training mandatory for all Anganwadi Workers (AWW). 26. The training material and training strategy for home based newborn care is being finalized. In the initial phase, it is proposed to be piloted at an ICMR trial site and may further be taken up in 5 erstwhile EAG states UP, MP, Orissa, Rajasthan, and Bihar (under the Indian Norway Project Initiative). A committee has been formed to review and recommend use of antibiotics by ANMs (Inj. Gentamycin), and trained community based workers (cotrimoxazole) such as AWW, Accredited Social and Health Activist (ASHA) and link worker. Guidelines have been developed and disseminated for provision of essential care for the newborn and the sick child at the FRUs. In addition, several other child health policies are in different stages of development. Based on recommendation received from WHO and UNICEF, GOI has approved an increase in the age for vitamin A supplementation up to five years. Similarly, technical recommendation received to provide iron syrup for children less than 2 years of age are under consideration. 27. With immunization one of the thrust areas under NRHM, several efforts are being implemented to improve routine immunization. Alternate vaccine delivery systems have been established in most states and immunization weeks have been planned to cover hard to reach areas in EAG and NE states. The surveillance guidelines for measles have been developed and disseminated. No vaccine stock-out of more than 1 month has been reported at National or state levels and the required number of Auto-Disable Syringes have been supplied. Injection safety policy guidelines developed and disseminated. First lot of hub cutters supplied to few states and funds for constructing safety pits at PHCs has also been released. Areas of Concern: (a) (b) (c) (d) (e) (f) (g) There are no intervention for new born care and management of sick children in non IMNCI districts The overall focus in the monitoring of child health performance has been on inputs and not on outcomes. Guidelines for home based newborn care and policies for micronutrients such as use of Zinc in diarrhoea management are yet to be finalized. The implementation pace of IMNCI is constrained by the limited pool of state level facilitators and technical assistance available at district level. There are enough national trainers, but they have limited mobility to the States. Roles for ASHA and AWW and ANMs in mobilizing and delivering child health need to be clearly defined to gain maximum impact at village level and minimize confusion over responsibilities and duties. The shortage of drugs at SC / village level will affect implementation, if not addressed on a priority basis. Referral mechanism for sick newborns and children not yet clearly defined at central level, though initiatives have started at state level.
- 11 -

Agreed Actions: (a) (b) (c) By March 2007, evolve strategy to increase training institutions for IMNCI at national and regional levels including greater involvement of institutions from NGO and private sector. By December 2006, finalize guidelines for Home Based New Born Care. By December 2006, finalize policies on Micronutrients and extended authorizations for use of Gentamycin and Co-trimoxazole.

IV. e. Family Planning: 28. Since the last JRM in February 2006, several steps have been taken to assure quality of contraceptive services, especially for sterilization. Quality Assurance Manual for sterilization services has been finalized and the service standards have been updated. Recently clear guidelines have been developed on empanelment of doctors, Family Planning indemnity insurance scheme, incentives for team of providers and ASHA /AWWs. The Non Scalpel method of vasectomy is being promoted in all states and initial trends suggest increased acceptance, especially in the states of Madhya Pradesh, Rajasthan, Jharkhand, Himachal Pradesh, Punjab and Chhattisgarh. 29. A comprehensive strategy for enhancing the use of spacing methods is being taken up by the MOHFW. This will focus on capacity building of ANMs for IUD insertion, BCC and Quality of Care as well as introduction of IUD asepsis kits along with other spacing methods is under formulation. A study to assess the feasibility of introduction of Centchroman through the public system is in another initiative in this regard. The RSS Division needs to work with focus states to develop their capacities for monitoring and analysing service delivery performance and quality across the districts as per national standards. Recently Government has approved piloting a Social Franchising model on IUD service provision in 3 States of Rajasthan, Gujarat and Bihar, which is a step to actively involve the private sector as public-private partnership. Areas of Concern: (a) In spite of the inclusion of CuT380 and the EC in the array of spacing methods, the need for increasing access to quality spacing method services emerged during the field visits. District program managers and service providers are unaware about details such as the duration of contraceptive protection provided by the IUD Cu380 or the availability/use of emergency contraceptive pills. As a result, these methods are not receiving emphasis at the point of service delivery. The JRM is recommending inclusion of Emergency Contraceptive pills in the ASHA drug kit. The feasibility of this should be carefully assessed through a study before including these pills in the ASHA kit.

(b)

Agreed Actions: (a) (b) (c) (d) By December 2006, finalize a strategy and plan for enhancing access to spacing methods. By December 2006, finalize Standard Operation Procedures for organizing FP camps incorporating appropriate protocols for Quality Assurance. By January 2007 initiate regional seminars in focus states to disseminate Quality Assurance guidelines and sterilizations standards, and contraceptive updates to the States program managers and service providers, including nurses. By December 2006, pilots for PPP in FP service provision including injectable contraceptives are established.
- 12 -

IV. f. Training 30. There is considerable progress in Training since last JRM and overall training management at national level is now better streamlined. Operational guidelines including strategies for organizing training in RCH-II program have been developed and disseminated to states. 31. So far, 33 states have developed Comprehensive training plans (CTPs). Under the Professional Development Course has for District Health Officers (DHOs) so far, 606 District Health Officers have been trained and an evaluation of the performance of trained DHOs is being planned. 32. Guidelines for selection, training and compensation of ASHA as well as guidelines for setting up the support system have been developed and circulated to the States. UP and Rajasthan have made considerable progress in the selection and training of ASHA this year. All other States are at various stages in constitution and training of district, block and state level training teams. 33. Several skill-based training programs are planned by Federation of Obstetricians and Gynaecologists of India (FOGSI) and some Medical Colleges including life saving skills in anaesthesia. However, with exception of a few states such as Gujarat, institutional arrangements to offer these trainings are still to be formalized between medical colleges and health departments in many states. 34. Several states are still continuing with a range of integrated skills training initiated during RCH I. As technical strategies of Maternal Health, Child Health and Family Planning have changed and new guidelines are developed, there is a need to revise such training plans in the light of RCH II training guidelines. 35. There is need to ensure greater coordination at the state and district level to ensure that training is linked with appropriate up gradation of facilities and staff deployment, which should result in improving services. Areas of Concern: (a) (b) (c) (d) (e) (f) Even though the states have developed comprehensive training plans, the visits to some states revealed that district needs have not been incorporated in the CTPs. A high level of vacancies has been observed among the faculty of the training institutes, and there is a lack of training aids and pedagogy skills among the existing trainers. The role of the Training Division needs to be revisited in light of the emerging training needs. The CTPs are not linked to the HR plans. There needs to be a rationalization of facilities, human resources, and training for effective service provision. A systematic assessment of impact of training on job performance and skill development is not being carried out. Enhanced supervision is also required to ensure that skills have been adequate and leads to improved service delivery. As recently directed by MOHFW, all states should ensure gender mainstreaming in RCH II trainings.

Agreed Actions: (a) By January 31, 2007, the MOHFW will assess the infrastructure and HR needs of SIHFWs, CTIs, and RRCs.

- 13 -

(b) (c)

By June 2007, the states will review their CTPs and PIPs to ensure rationalized trainings and connect them to service provision. By January 31, 2007 a section on supportive supervision will be incorporated into all training modules and guidelines for skills post-training skill assessment finalized.

IV. g. Innovations in Service Delivery 36. There has been further progress on innovations since the last JRM and there is a range of innovations that are being pursued in different states for improving service delivery. 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. Many of these innovations are in the early stages and one needs to further assess the implementation and impact of these innovations before scaling up. Some examples include: Delivery of vaccines through alternate delivery mechanisms, e.g. in Bihar, Chhattisgarh PPPs for training providers- Establishment of ANM training schools in partnership with the private sector in West Bengal; outsourcing MTP training to an NGO in Maharashtra and accreditation of NGO training institute in safe abortion services in MP Contracting: (i) Provision of new-born care services through private sector hospitals- e.g. Assam, Maharashtra; (ii) Contracting out of PHCs/APHCs to NGOs (e.g. Bihar and Arunachal Pradesh); (iii) Contracting in doctors in public health facilities (e.g. Maharashtra); (iv) Outsourcing hospital maintenance (e.g. Bihar) and hospital waste management in Gujarat; and (v) Referral transport and Ambulance Services through PPPs (e.g. West Bengal, Bihar, MP, Karnataka, Maharashtra, AP) Vouchers for safe delivery & management of obstetric complications through private providers in Gujarat Social marketing and franchising: (i) Social marketing of contraceptives (e.g. MP); and (ii) Social franchising of family planning & maternal health services (e.g. Rajasthan, Bihar) Mobile health vans (e.g. MP, Uttaranchal, Chhattisgarh, Bihar, AP) State-wide catch-up rounds for improving routine immunization, vitamin A and IFA coverage in Jharkhand through PPPs Community based monitoring: Monitoring through NGOs (e.g. monitoring of JSY, Sahiyya & routine immunization in Jharkhand); Jan Swasthya Abhiyan in Gujarat

37. Since RCH II implementation has started, 193 new Mother NGOs (MNGOs) covering 206 new districts have been added. A total of 404 districts are now covered by all 297 MNGOs. The capacity building of these NGOs is being continued through the 11 regional resource centres. Areas of concern: (a) (b) (c) The approval process is slow and only 97 MNGO projects have been sanctioned. Most of the innovations are still in early stages and require proper evaluation before scale-up to ensure that they are addressing critical gaps in the program and improving the utilization of services especially by the vulnerable populations. Since the last JRM there has been a significant improvement in approvals of MNGO and Field NGO proposals. However, it needs to be ensured that these

- 14 -

(d) (e)

efforts are able to improve services for the vulnerable population groups (remote/ tribal/ BPL/ SC/ ST etc). Limited cross learning amongst states and the absence of a central forum to disseminate successful experiences. Contracting process: Comprehensive guidelines for the contracting process not present, including for selection of NGOs, preparation of ToRs and contracts, M&E of NGOs, pay for performance clauses and contract management methods.

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

IV. h Demand Creation 38. Since the last JRM progress has been made in prioritising key communication messages including mass media efforts at the national level. The branding of the program has also been intensified. However, the field visits indicated that the awareness of the NRHM/RCH-2 is limited. Communication efforts proposed by MOHFW need to be supported by a welldesigned media strategy at states and districts. The MOHFW has for the first time emphasized intra-communication to ensure proper understanding of all health programs among the entire service delivery personnel and a rapid feedback mechanism, and is preparing a strategy for this. The physical infrastructure of the BCC Resource Centre has been established, however arrangements need to be formalized for the recruitment of adequate and qualified staff. 39. Field-visits and state reviews at the centre also indicate that though a range of IEC efforts are being undertaken by the different states in almost all cases there is no comprehensive BCC strategy at the state level and district level. Some states such as Rajasthan, Uttaranchal, Jharkhand, UP and Maharashtra have recently formulated or initiated the process of developing decentralized BCC strategies. However, there is need for other states to undertake this on priority. 40. Also, the capacity of states to plan and implement BCC activities at the state, district, block and village level is limited in most states. Mechanism for providing support to the states for developing and implementing a decentralized BCC strategy needs to be fast tracked. This had been identified as an agreed action during the last JRM. State level and district level IEC capacity needs to be augmented by filling existing vacancies, building staff capacity and exploring options for outsourcing state and district level IEC activities. Private sector inputs may be identified for capacity building. 41. Mechanisms for synchronizing mass media efforts with interpersonal communication and outreach efforts need to be established. It is also important to establish mechanisms for monitoring and evaluation of communication efforts at all levels. 42. The MOHFW has identified Age of Marriage, Institutional Delivery, and Prevention of Sex Selection as important themes to be covered by the national mass media campaign.

- 15 -

Monitoring of the implementation of the PNDT Act has been taken up both at the Centre and the states. Teams from the MOHFW have undertaken visits to facilities in states, and in some instances were not given access to the facilities. The states will need to support the Centres monitoring efforts to ensure its effectiveness. Some states have reported surprise raids on facilities to assess their compliance with the Act. Areas of Concern: (a) (b) (c) (d) (e) (f) There is significant weakness at the state and district level IEC units. This needs to be addressed by filling existing vacancies, building staff capacity and exploring options for outsourcing state and district level IEC activities. The MOHFW has established a BCC Resource Centre. However this does not have adequate staff or capacity as agreed in the National PIP. There is no standardization of messages for the RCH II program. Roles and responsibilities of different workers for communicating health messages needs to be clarified and consistency of messages needs to be ensured. There is lack of clarity among providers and clients regarding the purpose and benefits of the JSY and ASHA scheme IEC is very weak in the Northeast. The linkage between RRC and IEC division needs to be strengthened. Adequate attention is not being given towards monitoring of sex ratios at birth.

Agreed Actions: (a) (b) (c) (d) (e) By January 31, 2007 the BCC unit at the national level will be fully staffed with clear roles, responsibilities and deliverables for the staff. By March 31, 2007 and May 31, 2007 the BCC units at the state and district levels for 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. By January 31, 2007 Centre to put in place a mechanism to support states in development of a comprehensive and integrated BCC strategy. By December 2006, organise TA for capacity building of state counterparts to plan, implement and monitor BCC activities. By June 2007 strengthen the ASHA/AWW/ANM training with interpersonal communication skills to adequately address patient concerns and empower patient decision-making.

IV. i. Monitoring and Evaluation 43. The monitoring format for capturing routine service statistics on monthly, quarterly and annual basis was finalized by the M&E Division and sent to the states. Most of the process indicators agreed to in the RCH II NPIP have been included in these formats and some states have also started sending the data in the revised format but full data is not still available. 44. The fieldwork of third National Family Health Survey (NFHS-3) has been completed and dissemination of results has started. Final data from five states is currently available and data for all states should be available by next JRM. DLHS-3 preparations are underway and will start as per the agreed work-plan. 45. There has been progress in finalizing protocols for service quality reviews with support from UNFPA. The piloting of an integrated manual covering all RCH program components

- 16 -

will start in one district in each of five selected states i.e. Karnataka, Maharashtra, Uttaranchal, West Bengal and Assam, and two districts of UP. Areas of Concern: (a) The whole process of implementation of the agreed M&E strategy has been inordinately delayed, as the M&E division did not receive the required feedback from the other divisions/agencies on time. As a result, assessing the results of the program, an important focus of RCH II will be difficult. Several management process indicators were envisaged to be captured through a management review. The Indian Institute of Management, Ahmedabad was contracted to evolve this methodology. However this has been delayed and the report is yet to be submitted. It has now been decided to go straight to the piloting stage with selected EAG and non-EAG States. Most states are still not collecting disaggregated data on institutional deliveries and immunization coverage, which was agreed to be one of two criteria for determining performance bonus of the states from Year 2. There is likely to be considerable delay in states adopting the new monitoring format since they would need to modify their underlying systems especially at the grass root level in order to generate the necessary data. Further, states have limited capability in analysing the data in order to improve quality of decisions. UNFPA to provide TA in preparing these guidelines. There has been no progress at the central level on community based monitoring, a key component for triangulation of data. However, Gujarat on its own initiative is experimenting with community monitoring and reporting in partnership with Jan Swasthya Abhiyan (JSA) network. TA to be provided. While MOHFW would like to have annual data on the program indicators, appropriate systems are not yet in place. The time taken for the collection and analysis of data raises concerns about the capacities of International Institute for Population Sciences, the nodal agency coordinating the DLHS surveys.

(b)

(c) (d)

(e)

(f)

Agreed Actions: (a) (b) (c) (d) (e) (f) By October 31, 2006, reactivate the M&E Working Group By January 31, 2007, develop a pilot proposal for community based monitoring and prepare a short list of appropriate institutions for its implementation. TA to be provided by early November 2006. By November 2006, TA to be provided for developing a framework for triangulation. By January 31, 2007 organize series of state level workshops to train state and district level staff in the reporting information in the new monitoring format. By October 31, 2006 develop TOR for independent management review of process indicators including rapid facility assessments. By January 2007, initiate the process for organizing regional workshops with State / District PMUs to disseminate the M&E framework and the revised MIES format.

IV. j. Procurement: 46. There has been a good progress in implementation of several agreed actions to improve procurement arrangements despite some initial delays. All procurement activities of health and family welfare wings of MOHFW including that of RCH have now been brought under the oversight of the Empowered Procurement Wing (EPW) headed by a Joint Secretary who is supported by 3 Directors and other staff. Essential infrastructure (computers, printers, furniture) and support staff to the EPW have been provided by DFID. To streamline the
- 17 -

clearance process in MOHFW, an Integrated Purchase Committee under Director General of Health Services has been established. The MOHFW has disclosed the RCH procurement manual, and procurement plans for FY 2006-07 and list of firms with valid WHO GMP certificates on their web site. Recently a steering committee has been set up to provide policy guidance to EPW. 47. The procurement capacity building has started with training of 40 procurement staff from EPW and some states during early 2006. With support from DFID technical assistance grant, MOHFW has positioned consultants (Crown Agent) to build capacities of EPW. The consultant has completed initial assessment of procurement and logistics capacity of MOHFW and states of Tamil Nadu and Orissa, and submitted inception report with their proposed work plan in July 2006. The consultant is currently mapping the skills of EPW staff and will prepare a comprehensive capacity building plan to address weaknesses identified. In addition, 6 full time national consultants are being recruited by Crown Agent to support EPW. 48. In consultation with states, MOHFW has identified drug inspectors for building capacity in assessing Good Manufacturing Practices (GMP). A set of guidelines have been prepared for these drug inspectors based on technical note prepared by the Bank consultant on comparison of WHO GMP guidelines with that of Indias revised Schedule M. The workshops for these inspectors are scheduled to begin from November 2006. A panel of 6 independent experts has been set-up to participate in WHO GMP inspections carried out jointly by central and state drug inspectors. These experts will also undertake random inspections of GMP certified companies to assess compliance. These initiatives are being supported under the Bank financed Food and Drug Capacity Building Project. 49. The EPW has prepared a compendium of technical specifications for 800 equipments, which will help in enhancing generic nature of specifications, thereby increasing competition. In addition, the first Market survey of pharmaceuticals goods has been completed which will help in deciding the lot sizes and qualification criteria for future purchases. The MOHFW has now set-up a manual database for monitoring complaints, which requires to be computerized by March 2007. 50. MOHFW has shared the draft TOR for quality and quantity survey, which is currently being reviewed by the development partners. These efforts of MOHFW to address fraud and corruption are being supported by all development partners. The Bank has issued request for proposal for hiring consultants for post review of health projects. For undertaking such review MOHFW requires to guide states and districts to establish appropriate system providing data listing all procurement activities undertaken. There is a need to urgently address the gaps in logistics and supply chain management to ensure the timely availability of necessary drugs/supplies. Though a study has been undertaken by Crown Agents, the action plan on the findings is not known. Areas of concern: (a) Non availability of essential pharmaceuticals included in the RCH Kits and supplies in many states partly due to their inability to undertake procurement and partly due to delay in MOHFW decision to decentralize such procurement and consequent late release of funds. Slow progress in appointment of procurement agent following international competitive bidding procedures. It is however understood that MOHFW is in advanced stage of discussions with some UN agencies to supply essential RCH commodities. Already MOHFW has entered in to a contract with UNICEF for the supply of auto-disabled syringes.

(b)

- 18 -

(c)

(d)

(e)

Delay in implementation of agreed actions for effective implementation of revised Schedule M, such as organizing workshops for the inspectors using new technical guidelines. This is an important action for considering NCB procurement of pharmaceuticals under pooled financing. It is also important to institutionalise participation of agreed external experts in WHO GMP certification process. Need for evolving a business plan for the EPW clearly defining its status (registered society/MOHFW department) and scope of work (procurement/oversight) for RCH, recently approved Tuberculosis II and pipeline projects especially HIV/AIDs and Vector Borne Diseases Control. The role of EPW in addressing logistics and supply chain management based concerns identified by the review undertaken by Crown agents also requires attention in this plan. Such business plan will determine the staffing and capacity building of EPW. Continuity of EPW leadership, especially Joint Secretary and Directors, is critical to sustain important initiatives started by EPW.

Agreed actions: (a) (b) (c) By October 20, 2006 MOHFW to confirm procurement arrangements with UN agencies for FY 2006. By November 31, share draft TOR and RFP for recruitment of procurement agent with development partners. By November 1, 2006 MOHFW will complete the workshop for identified drug inspectors in application of guidelines for implementing Schedule M and ensure participation of external experts in the inspections for WHO GMP certificates.

IV. k. Financial Management 51. MOHFW sustained RCH program financing despite the protracted delay by development partners in finalizing their approvals. MOHFW has started providing block grants to states (flexible pool) to finance approved state implementation plans from 2005-06, which is a major shift from its earlier approach of scheme-wise releases. In 2005-06 MOHFW released Rs 898 Crore out of Rs 1523 Crore approved for state PIPs. In addition an amount of Rs 900 Crore has been released till September 2006 (first half of FY 2006-07), which together with the unspent balance of Rs 504 Crore at the beginning of the financial year 2006-07 amounts to approx 90% of the approved allocation for 2006-07. The reported expenditure for RCH II program activities for state level activities in 2005-06 is Rs 389 Crore (43 % of the fund transfers) and cumulative till June 2006 is Rs 473 Crore. Having released a large quantum of funds to the States it is important to concentrate and focus on program strengthening and financial management at state and district levels to ensure proper and timely utilization of funds and reporting in accordance with approved plans. 52. There has been a distinct streamlining in the funds flow process from the MOHFW to the States both in terms of timeliness and quantum and the Financial Management Group (FMG) is commended for this effort. Key factors contributing to the improvement are the introduction of electronic transfer of funds to States and the decision to release 75% of the 2006-07 allocation on the basis of provisional Utilization Certificate (UC) received from the States for the year 2005-06. The FMG has also organized training for finance staff at States and districts, developed accounting guidelines for districts and sub districts and placed all financial information (fund release, utilization, finance manual) on the web site of MOHFW to enhance transparency. 53. Inspite of rigorous follow up and repeated reminders, there are considerable delays in submission of Financial Monitoring Reports (FMRs) by the States and UTs and till date

- 19 -

FMRs from 32 states have been received for the quarter that ended in June 2006. The delay to a large extent is linked to the gaps in finance staffing in States and Districts (approx 50%). A review of the consolidated FMRs indicates that the FMRs are not in line with the formats documented in the FM manual, resulting in risk of accuracy and correctness of the reported expenditure. A review of the management audit carried out by FMG indicates that many States may have over reported expenditure by reporting transfers to districts/ blocks as expenditures1. The FMG has carried out an analysis of the reported expenditure by project activities across States, however the expenditure by individual States reported has not been compared/ analysed with the activity budget in the approved State PIP. Going forward it would be useful and necessary to monitor progress of each State against approved PIP and further disaggregate it by districts once the DAP are in place. The JRM was informed that the constraint in doing comparison is the varied forms in which the financial data has been presented in the PIP. It is suggested that this could at started with at a component level to begin with. In addition expenditure on central level activities (BCC/IEC, M & E) by the technical divisions at MOHFW are not being reported to FMG resulting in incomplete reporting of RCH program expenditures. 54. Audit reports for FY 2005-06 have been received from only 9 States and the rest are expected by November 2006. The audit of central level expenditures at MOHFW by the C& AG as per approved TOR) is yet to commence. The FMG has carried out management audit in 8 States. These reports indicate financial and program constraints at State and District level due to lack of adequate financial delegation, financial risks due to multiple bank accounts and the need for a uniform accounting system reviews. Areas of concern: (a) Funds for certain activities such as BCC/IEC, NGO, M&E in States continue to be approved and released by technical divisions. In addition expenditures incurred at MOHFW on central activities are also not reported to the FMG. This results in the FMG not being able to monitor the fund transfers and the compile expenditure for the entire There is a need to improve the quality, correctness and timeliness of the FMRs and emphasize reporting in the formats provided in the FM Manual. It is also important to monitor the expenditure reported by the States against approved PIP. Despite several reminders and rigorous follow up, delay in submission of the audit report for the year 2005-06 and the low audit fees, which could impact quality and coverage is a cause for concern. Delay in submission could affect the disbursement from the development partners for eligible expenditures incurred in the year 2005-06 as these are to be disbursed against acceptable audited financial statements. The management audits conducted by the FMG indicate constraints (fiduciary and operations) at the State and district level. These need to be followed up and addressed in a systemic manner.

(b) (c)

(d)

Agreed Actions: (a) By November 15, 2006 all states and MOHFW (contingent upon States submission) will 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.

The FMG management review in Orissa carried out in December 2005 indicates the actual expenditure of 7.45 % for six month period ended Sept 30, 2005, while the State has reported an expenditure of 90% in the FMR for the year 2005-06. - 20 -

(b) (c) (d)

By November 1, 2006 all states will share FMRs for six month period ending on September 30, 2006 and MOHFW will share the FMRs with pooling partners in the agreed format (contingent upon States submission). Immediately MOHFW will establish a system for quarterly financial and procurement reporting of central activities from the technical units to FM. Develop process of a structured management audit with specific TOR and outsource it to complement the review by FMG.

IV. l. Convergence: 55. The National PIP outlined that convergence groups would be formed in all states by July and job responsibilities of ANM and AWWs would be defined and disseminated for deeper convergence with ICDS/DWCD. Decentralised planning with PRI and other departments has also been planned as a part of the strategy. 56. In terms of convergence between health and ICDS, the Ministry of Women and Childs National Plan includes IMNCI as part of the responsibilities of the AWWs. At the field level the ANMs conduct monthly health days at AWCs with the support of AWWs, while the IMNCI, AWWs and ANMs are trained together in IMNCI. They also co-ordinate home visits and ensure a regular flow of drugs from the ANM to the AWWs. 57. The PRI and the health department are coordinating the selection of ASHA, the management of the RKS and untied fund. ASHAs will be given two days training in HIV/AIDS with support from NACO. Agreed Actions: (a) The MOHFW and the States will need to seek the involvement of the following departments: Rural Development for road connection for PHCs, renovation of SCs, installation of hand pumps, construction of toilets. Forest department, particularly in tribal areas for service delivery, emergency referral transport. Education department for school health, health education, adolescent anaemia. (b) Clarify the roles and responsibilities of ANM, AWW and ASHAs when planning joint activities or seeking opportunities for convergence. THE SYNERGY BETWEEN NRHM AND RCH-II 58. The National Rural Health Mission launched by the Government of India comprises of five components viz: 1. RCH-II 2. Immunization 3. Additionalities under NRHM 4. Disease Control Programme and 5. Convergence. The States are required to prepare the NRHM PIP taking cognisance of these components, thereby facilitating integration of RCH-II with the other Programmes. The Additionalities under NRHM have been envisaged as instruments for strengthening the basic Infrastructure of the Public health Systems and ensuring architectural corrections for better and holistic implementation of the Programme. The formation of State and District Health Missions and Societies, Rogi Kalyan Samitis, and State and District Programme Management Support Units as well as initiatives such as ASHA, IPHS Standards and Flexible Funds made available to various facilities is a part of this systemic approach and will have a synergistic impact on outcomes of RCH-II.

- 21 -

PROGRESS ON THE GROUND: 59. The flexibility provided under RCH-II coupled with the NRHM Institutional arrangements and Additionalities has led to a perceptible change in the mode and quality of health services delivered on the ground. New States like Chhattisgarh and Jharkhand have made impressive gains and there have been a number of innovations, e.g. the Chiranjivi Scheme in Gujarat, the Moped Loan Scheme in Mizoram, and the involvement of PRIs in West Bengal. However, UP has been reluctant to use the opportunity provided by RCH-II/NRHM. Progress in the North East states has been slow but enhanced technical assistance through the NERRC will provide the much-needed support. V. AGREED KEY ACTIONS TO BE COMPLETED BY NEXT JRM (a) (b) (c) 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 state managers at state and district levels. Finalize the IMEP and initiate regional dissemination of this 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 skillbased training, by the States/Procurement Division, so that the trainees have the facilities to practice the newly acquired skills in adherence with guidelines.

(d) (e) (f) (g)

60. The implementation status of priority actions agreed to in the First JRM is provided in Annex 4. The priority actions agreed to in the Second JRM together with agency responsible and time line are listed in Annex 5. Reports on performance of each state in various functional areas together with suggested actions are detailed in Annex 6, while Annex 7 provides status of performance of programme divisions. OBSERVATIONS OF THE JRM CHAIRPERSON MOHFW: (a) MOHFW divisions should know what services have actually improved on the ground and this requires more frequent field visits. (b) The RCH II program implementation plans should clearly reflect all sources of funding including contributions from the state and DP. (c) Feedback from Regional Directors should also be taken into account in assessing program performance.

- 22 -

(d) Inter-personal communication is very important for Behaviour Change. This requires appropriate training to village health committee members and ASHA and flexible funds could be provided for this purpose. (e) To establish a Standing Committee on Monitoring and Evaluation to oversee the flow of information from the States on the MIES and agreed indicators, on a dynamic basis. (f) To circulate enough copies of the National PIP of RCH II to all the States/UTs and also translate them in Hindi. (g) To organise workshops on M&E framework and MIES on regional basis. STATES (a) States should effectively use the existing divisional/zonal structures for improved monitoring. If required, these institutions could be strengthened by providing consultants. (b) With support from the development partners, states should establish appropriate logistic management systems to track movement of commodities and maintain inventories. (c) Monthly health days should be conducted scientifically ensuring quality inputs such as trained staff supported by full equipment and medical supplies. Such inputs can make a very big difference. However, performance of this service should be monitored by the State Mission Directors. (d) For effective service delivery and increased use, it is important to connect several related activities such as training, availability of medical supplies, social mobilization, and referral transport. (e) Ensuring quick prosecution enhances the impact of Prenatal Sex Determination Act. (f) For conducting deliveries at sub centres, ANM should be aware of danger signs and facility where they should refer in case of an emergency. (g) It is important to track medical officers trained in anaesthesia/emergency obstetric care to ensure that they are posted in a facility where their skills are utilized. (h) Strengthening nursing cadre as a solution to address shortage of doctors. Such strategies should be included in the PIP. (i) Training of Traditional Birth Attendants should be seen only as a stopgap arrangement. Eventually all states should focus on deliveries by Skilled Birth Attendants. (j) Where necessary, neighbouring States can be requested to provide training on such as Multi Skilling, ANM and SN Training. (k) AYUSH doctors should not be seen as a replacement for allopathic doctors. The emphasis should be on providing people with a choice. (l) Partnerships with agencies such as Red Cross are important for establishing blood storage facilities for full operationalisation of FRUs. (m) All innovations should be adequately evaluated before scaling up. (n) Ensure that financial and administrative powers are delegated at various levels including block and sub centre. Purchasing powers could be delegated to districts while the states can fix rates.

- 23 -

(o) Clarify roles and responsibilities of the PMUs and ensure linkages between DPMUs, SPMUs, and the Central PMU. HR planning for regularization of PMUs, career progression mechanisms, performance appraisal, and salary review. (p) The PMUs in the States and districts need to act as information drivers for facilitating the collection/collation of disaggregated data by leveraging the advantages of information technology. (q) States to look at Block level PMU arrangements in their PIPs. (r) Urban RCH activities to provide for link workers for urban slums, and these workers to be linked to urban health posts. (s) Trainings for SBA, IMNCI, and Multi-Skilling to be taken up on priority. (t) CHCs should first be upgraded as FRUs, and then scaled up for IPHS standards. (u) DPs to see that the State partnerships emphasize on the critical gaps of NRHM/RCH-II, such as establishing Procurement systems, based on TNMSC model. (v) DPs may help GoI to organize training programmes on Multi-Skilling, in collaboration with medical colleges, especially for NRHM high focus states. (w) NE Division of MOHFW will coordinate all the training activities of NE States. (x) There is some confusion over NRHM and RCH-II PIPs. It may be noted that the existing RCH-II PIP will be a part of the NRHM PIP for the State. States need not prepare a separate RCH-II PIP for NRHM. (y) The IT infrastructure established under various other State/National partnership programmes such as TB/Malaria need to converge in order to established an effective M&E system for the complete health sector. (z) States should take action on implementation of E-banking.

- 24 -

ANNEX 1 JRM-2 PROCESS MANUAL

JOINT REVIEW OF RCH-2 PIP

(Government of India, State Governments and Development Partners)

PROCESS MANUAL

August 2006
Ministry of Health & Family Welfare Government of India

- 25 -

Introduction The RCH2 programme was launched in April 2005 in all states of the country. Programme envisages delivery of evidence-based package of services along with strengthening institutional capacities for achieving National Population Policy and Tenth Five Year Plan goals. This manual details the structures and processes to be adopted during the second Joint Review of RCH 2 programme scheduled in the month of September 2006. It is proposed to cover all the 35 states and Union Territories in the review. The Focus of review would be to take stock of the progress made on the implementation of the PIPs during the first half of 2006, identify key implementation bottlenecks and delineate correctional measures needed. GOI, State Governments and the Development Partners will be participating in this review exercise. Design The review will have the following components: PRE MISSION 1. Pre Mission Activities Completion of RCH 2 process Indicators datasets by states 2. Intensive Programme performance review in 18 high focus states GOI/DP visits to state and districts Regional Meeting of all NE states including state visits MISSION 3. National Level programme review Review of the Progress on work plans of Programme divisions Review of the Progress on work plans for all states and Uts 4. Wrap up In 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. Completion of RCH 2 process Indicators datasets by states The RCH 2 National PIP refers to 13 process indicators for the purpose of monitoring the programme at the national level. As outcome/output datasets are not available, the mission will largely rely on information available on process indicators. It is acknowledged that data for some of the indicators may not be available with the state governments. The datasets along with the definition of indicators and sources of information is appended as annexure of this manual. States will be requested to send the desired information to the GOI by 27th August 2006

- 26 -

A team of GOI and DPs will analyze Datasets received from the states. These will be shared with DPs going for field visits to particular states. For non-EAG states these datasets will constitute an integral part of JRM report and state reports will be generated on the basis of performance recorded through these datasets. Intensive Programme performance review in 18 high focus states Government of India/Development Partners visits to state and districts

As per the terms of Reference the main focus of these visits will be as follows: Governance issues: Assess overall progress in establishing key changes in programme management within the health sector as envisaged in RCH-II guiding documents: - Arrangements and capacity at State and district level for prioritizing vulnerable groups (for services, accountability and impact) - Integration of various societies at the State and District level into one common Health and Family Welfare society - Strengthening of State and district Programme Management Support Units (PMSUs) - Mechanisms for convergence/co-ordination with other departments such as NACO, ICDS, RD etc. State ownership towards RCH-II: - Process of developing State annual plans (level of decentralized bottom up planning, level of delegation to implement the plans, etc) - Process of signing MoUs between Centre and States - Prioritization of worse off districts and vulnerable groups in planning exercise - Process of district PIP development and approval

Review of the implementation progress of State PIPs and district action plans against equity based prioritization by assessing the extent to which Resources are being allocated and used on a rational basis to redress unequal health outcomes State and district plans meet human and infrastructure resource gaps in underserved areas including recruitment of community mobilizers such as ASHAs Systems and processes that improve access to services by the vulnerable groups, especially SC/ST/adolescents and women are in place Mechanisms for incorporating perspectives of vulnerable groups in planning, implementation and monitoring of services are in place Accountability of the program managers and providers to district and village level community structures (PRIS/Village Health and Sanitation Committees) is being ensured.

Review progress against equity and evidence based prioritization of interventions to meet MDGs Progress on adaptation of guidelines for the operationalisation of technical strategies in RCH 2 Progress on CTP (comprehensive training plan) for the state Review State PIPs and physical progress on ground to track prioritization of technical interventions, e.g. strengthening of Emergency obstetric care, training of Doctors in

- 27 -

Anesthesia and EmOC, newborn care, IMNCI, expanding contraceptive options and access, adolescent health etc. Progress on innovations: Plans for public private (including NGOs) partnership for advocacy and improved service delivery, e.g. BCC, referral transport, outreach services, adolescent health, EmOC, etc Health financing/insurance

Financial management and Performance based funding Whether resource allocation have been prioritized to worst off districts and pockets of vulnerable groups Review financial performance for timeliness, quality of financial reporting and audited statements

Review of Progress on following components of the PIP BCC: State and district BCC plans, Human resources for BCC, capacity development plans if any and key issues identified for BCC Training Infrastructure including training faculty, mechanisms for post training follow up, linkages with medical colleges and with professional associations for training M and E : institutional mechanisms for data collection, reporting systems, analysis and feedback , capacity development and presentation of data Procurement Mechanisms: State guidelines for procurements, decentralized procurement plans, quality checks and Logistics MNGO scheme: Work plans for MNGOs, physical progress

Each State team will generate a 2-3-page report after completion of the state level visits. i) Field Visits to Identified districts

It is proposed to conduct field visits to identified districts (at least one / two districts per state), by a team comprising of the representatives for Government of India, Development Partners and participation of some state governments. The visit to district is proposed to be at least one district in the 15 states (other than the states of Bihar, Orissa and One NE state) and at least two districts in the states of Bihar, Orissa and One NE states. Preferably the districts should be chosen covering good performing districts and 150 backward districts issued by the Planning Commission in 2004 (Refer Planning Commission Classification of List of Backward Districts). State Health & Family Welfare Secretaries of Gujarat, Karnataka and Tamil Nadu will be requested to join the mission while taking up field visits in Bihar, Orissa and One NE states as the representative of state government in the mission team. States of Bihar, Orissa and One NE state (TBA) are selected on a random basis (after excluding states covered in the first JRM). In these three states at least two districts in Bihar and Orissa and one in identified NE states will be covered. The State will identify names and number of districts (in consultation with GOI and DP team) for conducting field visits to service delivery facilities and to capture perspectives from clients.

- 28 -

The facilities in each district to be visited during the review mission will be as follows: a. 2 CHCs b. 2 PHCs c. 2 Sub Centres These facilities will be decided by review team for the district in consultation with district programme managers. Each State team will include one representative from Government of India, one or more representative from DP and representatives from concerned State Government. Following schema suggests filed visits.

State 1

District 1

District 1

Facilities 2 CHCs 2 PHCs 2 SCs

Facilities 2 CHCs 2 PHCs 2 SCs

Following programme of work is suggested for the State visits:

DAY 1

Briefing meeting at state HQ, discussion with programme manager and selection of districts. Cluster meeting with District Programme Managrs & CMHOs at Head Quarters. Field Visit-District HQ, 1/2 CHCs, PHCs and 1/2 sub centers Meeting with NGOs Debriefing with state programme managers and finalisation of the presentation for the National Level Review

DAYS 2&3 DAY 4

- 29 -

The visiting team members, to standardize the discussions and information gathering across Districts and States, will use a set of checklists. The checklists are: A. Checklist for Interview with Secretary, Programme Director, and DFW at state-level and CMHO at district-level B. FGD Guide for discussions with State/zonal/District Programme Managers C. Checklists for record review at District level D. FGD Guide for Women from VGs at Sub centre village E. Facility observation checklist F. Checklist for M&E All these tools are attached at Annexure of this document. Each State team will prepare a State report based on discussions held during the debriefing meeting at the State level, with special reference to pace of progress on the work plan as reflected in the state PIP, implementation bottlenecks, correctional measures required and technical assistance requirements. Complete work plan for the year should be used for the purpose of presentation, even if there is no progress on certain activities. Any additional activities are undertaken (other than included in the approved work plan) should be highlighted and presented separately. Wherever feasible the agreed timelines for follow-up actions be reflected. Major learnings from these field reviews will be used in the National PIP Reviews. Reviews at National Level The national review will be spread over two phases. First phase, 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 the national level. Programme divisions will present progress on the work plan, key bottlenecks and proposed correctional measures. The Terms of Reference for the different programme divisions are as follows: 1. 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 anesthesia in states - Services for Early and Safe abortion services - Guidelines for RTI/STI management - JSY Implementation - Any models on PPP

- 30 -

- Issues identified in the Last JRM 2. CHILD HEALTH: - Progress on National strategy for IMNCI - Operationalising IMNCI - New Born Care - Issues identified in the last JRM 3. FAMILY PLANNING: Upgradation of contraceptives standards QA; Follow up to Supreme Court Directives Engaging private sector Providing safety insurance cover Social marketing Issues identified in the last JRM 4. BCC Branding RCH Establishing BCC unit at national level and operationalisation State BCC plans and strategy 5. ARSH Implementation Plans Training related activities 6. NGOs ARCs and RRCs functionality MNGOs and FNGOs funded Number of proposals sanctioned Capacity building plans 7. TRAINING National Training Plan Status of CTPs from the states Training Guidelines for the states Issues identified in the last JRM 8. M&E Operationalization of revised monitoring format Finalization of Management Evaluation Methodology Finalization of Quality Assurance Mechanism Status of Evaluation system Triangulation of data and validation Availability of Information through MIS on following Monitoring 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 9. PROCUREMENT. - Guidelines for the states to streamline procurements
- 31 -

- Specifications for civil works 10. PROGRAMME MANAGEMENT ARRANGEMENTS - Status of establishment of Programme management support group - Status on SPMUs/ DPMUs, training status - Status on NHSRC/SHRCs 11. FINANCIAL MANAGEMENT - 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. - Delegation of financial powers: To program managers at state, district & 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 July 2006. Action taken report on Audit Observations. - Utilization Certificates (UCs): Status of UCs due by July of succeeding year. SCHEDULE FOR PRE- JRM STATE VISITS (from 28th August, 2006 14th September, 2006) States Chattisgarh Himachal Pradesh Rajasthan Jharkhand J&K Uttaranchal Uttar Pradesh Madhya Pradesh Bihar Orissa North Eastern States Teams GoI + DFID GoI + GTZ GoI + UNFPA GoI + USAID GoI +EC GoI + WHO (World Bank) GoI + EC GoI + UNFPA GoI + World Bank/ UNICEF GoI +DFID/ USAID GoI + World Bank + DFID + EC + UNFPA + USAID Dates 29th Aug. 1st Sept., 2006 29 Aug 1 Sept, 2006 29th Aug 1st Sept, 2006 29th Aug 1st Sept, 2006 4th Sept. 7th Sept.,2006 4th Sept. 7th Sept., 2006 4th Sept. 7th Sept., 2006 4th Sept. 7th Sept., 2006 4 Sept. 7 Sept., 2006 4th Sept. 7th Sept., 2006 11th Sept., - 14th Sept., 2006
th th th st

GoI Officers Dir (Stat.) Dir (PNDT) Dir (MH) DS (IEC) DD (DC) Dir (NRHM) AC (RSS) AC (MH) AC (Trg.) / Dir (RCH Fin.) AC (CH)/ Rajesh Kumar DC (MH/CH), DC (RSS), Dir (DC), Dir (RCH Fin.), CD (M&E)

Phase 2: 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.

- 32 -

Following process is suggested for the national review of states: Each State will make a detailed presentation and include not more that 15-20 slides spread over 25-30 minutes. The structure of the presentation will be along the work-plan and would cover the progress in work against the approved activities of the year, budget allocation and expenditure of each of the activities, implementation barriers, remedial actions and any technical assistance requirements for rolling out the plan. Concerned mission members who visited states ahead of JRM and generated a three-page report will also ensure that key observations from the mission reports are also incorporated in the presentation. Suggested Outline of the State Presentation

Work Plan Activity

Physical Progress

Budget Allocation

Budget utilization

Percentage Utilization (%)

Implementation Bottlenecks Remedial measures Technical Assistance Requirements if any

National Review (Phase I) 25-26th September 2006 Venue: 249, A, Committee Room, Nirman Bhawan, New Delhi Date 25th Sept., 2006 Session Forenoon Session Time 11.00 a.m. to 1.00 p.m. Program Div. (i) Procurement (ii) Programme Management arrangements (iii) Monitoring and Evaluation (iv) IEC (v) Family Planning (vi) Financial Management (vii)Training (viii) Maternal Health (ix) Child Health (x) NGO

Lunch Afternoon Session 26th Sept., 2006 Forenoon Session Lunch Afternoon Session

1.00 p.m. to 2.00 p.m. 2.00 p.m. to 5.00 p.m.

11.00 a.m. to 1.00 p.m. 1.00 p.m. to 2.00 p.m. 2.00 p.m. to 5.00 p.m.

- 33 -

National level Review of States (Phase II) 28th September to 6th October2006 Venue: 249, A, Committee Room, Nirman Bhawan, New Delhi Date Time 28th September, 2006 29th September, 2006 3rd October, 2006 4th October, 2006 5th October, 2006 6th October,2006 10.30 a.m. to 4.30 p.m. 10.30 a.m. to 4.30 p.m. 10.30 a.m. to 4.30 p.m. 10.30 a.m. to 4.30 p.m. 10.30 a.m. to 4.30 p.m. 10.30 a.m. to 4.30 p.m. States Bihar, Rajasthan, Orissa, Delhi, Uttar Pradesh West Bengal, Karnataka, Tamil Nadu Gujarat, Goa Uttaranchal, Jharkhand, Madhya Pradesh, Chattisgargh, Chandigarh. Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Tripura, Sikkim, Nagaland Andhra Pradesh, Kerala, Maharashtra, Andaman & Nicobar, Lakshadweep, Pondicheery. Himanchal Pradesh, Jammu & Kashmir, Punjab, Daman & Diu, Haryana, Dadra & Nagar Haveli

(Phase III) Wrap up to be held in New Delhi Date: 10th October, 2006

Time: 3 P.M. 4. Follow up Mechanisms The state-specific recommendations emerging out of the national -level review meeting will have to be followed up during the ensuing year. 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.

- 34 -

Annexure I CHECKLIST # A INTERVIEW WITH STATE/DISTRICT LEVELS PROGRAMME MANAGERS Note: This checklist is to be used in conjunction with completed state data sets received from the states. Institutional Arrangements: 1. Problems for not registering integrated district societies in all districts (Need to probe if more than 20 percent districts in the state do not have registered societies.) 2. Reasons for more than 20 per cent contractual vacancies in PMSU/DMSU/ Consultants. (Need to probe if time taken to initiate recruitment process, interviews held, and status on joining, dropouts on joining and turn over rates) Reasons for not completing induction training for all contractual staff (check from state information sheet) (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) 3. Reasons for more than 20 per cent vacancies for key programme managers position in state/districts. (Key positions in the district, zone and state level for operationalisation of the RCH 2 needs to be identified, level of vacancies, states plan to fill these vacancies Does State have a HR database?) 4. Role clarity and role conflicts between contractual PM staff and regular programme managers. (Matching JDs, reporting requirements, discussions on the possibility of conflicts and conflict resolution mechanisms) 5. Perceived contributions of SPMU & DPMU staff & possibilities of optimizing their outputs. Observations on competency and commitment of contractual staff. Mechanisms for redressal of grievances of contractual staff (Are there any processes set out for addressing concerns of contractual staff) Convergence: Community, Gender and PRIs 6. Level and extent of participation from DWCD/PRI department in state management structures. Are they members of State & District Society, did the members outline the meeting & formerly extended activities. (Discuss about meetings held at state level, level of participation from the collaborating departments in last two meetings, engagement in the planning process, clarity in responsibilities, any activities to be jointly executed by departments)

- 35 -

7. How gender/rights/Vulnerable community groups needs are being addressed in the state (States plans to have rights and gender mainstreaming including gender focal point and also thinking on reaching out to vulnerable groups such as SCs and STs, nomadic population) 8. JSY Roll Out related: (Percentage of districts launched JSY, State specific guidelines issued; plan for empanelment of private providers under JSY). 9. Engagement of PRIs (Role of PRIs in starting the process, plan any orientation of PRIs). How are PRI being involved in ASHA, VHP, trainings, SHG and any joint meetings)

Technical Strategies 10. Maternal Health/Newborn and Child health/Family Planning and ARSH ( Plans for SBA and operationalisation of Emoc, availability of drug kits, Contractual service delivery staff, outreach sessions for service delivery, and RCH camps,Plans for IMNCI and boosting child immunizations, promotion of NSV and spacing methods, roll out plans for the ARSH clinics) Trainings 11. Plans for skill up-gradation of service delivery staff to adhere with revised guidelines for technical strategies 12. State Training Plans, Training infrastructure, Human resources availability BCC/Urban Health and tribal health 13. Availability of plans

- 36 -

CHECKLIST # B GUIDE FOR FOCUS GROUP DISCUSSION (6-8 programme managers from state/zones/district)) Note: These FGD should be conducted at state/zonal level. A mix of programme managers for state/zone/district level should be invited for a group discussion. Key Domains: RCH2 Planning: 1. Role played by programme managers in formulating RCH2 PIPs 2. Adequacy and soundness of technical strategies in achieving RCH 2 goals District Institutional mechanisms: 1. 2. 3. 4. Job descriptions and clarity in new programme environment Reporting structures Work load issues including decentralization of administrative powers Financial autonomy

Contractual Staff for programme management 1. Perceptions on the role of PMSU 2. Possible areas of conflict 3. Suggestions for capacity building 4. JSY: 1. Difficulty in opening Joint accounts at Sub centers 2. Perceptions on clarity on JSY provisions amongst peripheral service providers 3. Communication on JSY Service provision: 1. Recruitment and availability of additional service delivery staff 2. Identification of facilities for 24 hour delivery 3. Identification of CHCs for FRUs Planning for Vulnerable groups: 1. 2. 3. 4. Plans for reaching out to inaccessible areas Current provisions for planning outreach sessions Adequacy of package of services Collaboration with ICDS and PRI in organizing service delivery for outreach sessions

- 37 -

CHECKLIST # C Record Review: District level Name of District:___________________ 1. 2. Date of Visit::__________________ Yes/ No

District Guidelines for Implementation of JSY Dissemination of guidelines amongst : Service Providers Community groups Outreach Session plan Key Elements: Coverage of inaccessible areas Additional staff hired Vehicle Deployment Plans 4. Regularity of outreach sessions

3.

Yes/ No

Percentage ____ of planned sessions held in last quarter. Proportion of Clients from VGs for Immunisation, ANC ,Institutional Deliveries , FP services

5.

Women from VG accessing services.:

6.

Logistics: Stock positions for Measles, OCPs and Condoms, AD syringes and any stock outs reported during the last quarter, Availability of commodity distribution system from district to peripheral facilities. Human Resources Planning : additional ANMs, SN and MOs

7.

- 38 -

CHECKLIST # D FGD Guide: Focus Group Discussion with 8-10 married women in Reproductive Age group for non-Sub Center HQ Village women from VGs). Key Domains: 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 at HQ 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.

- 39 -

CHECKLIST # E Facility Observation Checklist District:_____________________________ Name of Institution:_______________ Date of visit:____________________________ 1.

2.

3.

4.

5.

6.

7.

Service provision Routine Delivery Services (24 hours) Yes/ No Manage common obstetric complications Yes/ No Female sterilisation services Regular/ Periodic NSV Services Regular/ Periodic MTP Regular/ Periodic Staff availability Obgyn Specialist/Trained M.O Yes/ No Anesthesiologist/trained M.O Yes/ No Staff Nurses/ANMs at least (4) Yes/ No Lab Technicians Yes/ No Equipments and Supplies NSV equipments kit Yes/ No Gluteradelyde Solution Yes/ No RPR Test Kits Yes/ No Injection Magnesium Sulphate Yes/ No Capsule Doxycycline Yes/ No Functioning BP instrument Yes/ No Measles vaccine Yes/ No Facility Infrastructure Infrastructure Needs Assessment Done Yes/ No Plans for hospital bio-waste disposal Yes/ No Visual Privacy in labour room Yes/ No Visual privacy in OPD Yes/ No Back-up power facility Yes/ No Referral Services Availability of an ambulance or a outsourced vehicle for referral Client Convenience Covered waiting area Yes/ No Separate functional and clean toilets for Male/Female Yes/ No Signage to guide clients (information to client on user charges, timings) Yes/ No Record Review Average no of monthly Institutional Deliveries for last quarter ---------

- 40 -

CHECKLIST # F Monitoring and Evaluation 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. Do you have the M&E system in place in terms of: a. Necessary hardware (computer, printed registers/reports, sufficient stationery etc), b. Software (packages) c. Trained human resources 4. 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. 5. How have you been tracking performance? Explain? What initiatives have you taken in regard to: a. b. c. d. e. Coverage Quality of data- adequacy Timeliness Supervisory visits System of giving feedback and follow-up

(Check documents related to itinerary of supervisory visits, actual visit, feedback and follow-up) 6. Now that SCOVA/PMU are extended arms supporting you and the programme? a. Find out the extent of involvement of SCOVA/PMU staff members in monitoring of the programme? b. Discuss in detail the specific role of SCOVA/PMU in monitoring and review/collect minutes of the meeting?

- 41 -

Sr. No. 1

RCH INDICATOR % of ANM positions filled

Level of achievement 80%

Calculation of the indicator by the State& methodology of data collection in JRM Source of Information: Programme Data/Financial Data on Salary disbursement Type: Secondary Definition: Number of ANMs positions filled till date X 100 Number of vacant positions as on 1 April 2005 Vacant is defined as regular vacancies against sanctioned plus those approved for contractual appointments 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 a. 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

Annexure II Task to be performed in JRM Review

Analysis of data presented by the State

a. % of districts having fulltime programme manager for RCH b. Administrative and financial powers delegated

90%

Analyze data; discuss about vacant positions (if any) and explore if any steps have been initiated for filling in vacancies.

- 42 -

Sr. No. 3

RCH INDICATOR % of sampled state and district program managers aware of their responsibilities

Level of achievement 80%

Calculation of the indicator by the State& methodology of data collection in JRM 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 induction/orientation programme X 100 Number of Program Managers. Source of Information: Programme Review Minutes

Task to be performed in JRM Review Depending on the scores, the JRM can frame their questions

underwent

% of sampled state and district programme managers whose performance was reviewed during the past six months

60%

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

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? Examine data on logistics and discuss if any flaws are observed. Find out the logistics mechanism (indenting, procurement, disbursement etc) followed by the state

% of district not having at least one month stock of a. Measles Vaccine b. OCP c. Gloves

<10%

Number of programme managers Source of Information: Stock Register/MIS Type: Secondary This information has to be compiled from stock registers maintained at district level. Compile districtwise information for last six months by opening balance, received, distributed and balance (monthwise) Source of Information: FMIS Collect for two quarters Ask when districts were supposed to report and when reported

% of districts reporting quarterly financial performance in time

80%

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

- 43 -

Sr. No.

RCH INDICATOR

Level of achievement

% of district plans with specific activities to reach vulnerable communities

80%

% of sampled outreach sessions where guidelines for AD syringe use and safe disposal followed

80%

% of sampled FRUs following agreed IP and health care waste disposal procedures

80%

Calculation of the indicator by the State& methodology of data collection in JRM Type: Secondary Definition: Number of districts reporting quarterly financial statement on time X 100 Total Number of districts 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. 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 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

Task to be performed in JRM Review subsequently areas of reviews and questions could be framed for district visits 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

AD syringe logistics in terms of supply and distribution can be verified at district level and few ANMs can be asked related questions

(MIS doesnt capture this information)

- 44 -

Sr. No.

RCH INDICATOR

Level of achievement

Calculation of the indicator by the State& methodology of data collection in JRM 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 Source of information: MIS Type: Secondary Definition: Number of 24hrs PHC conducting 10 deliveries per month X 100 Total Number of 24 PHCs in the state

Task to be performed in JRM Review

10

% of 24 hrs PHCs conducting minimum of 10 deliveries per month

50%

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%

Compile information for 6 months by districts Source of information: MIS/Programme Type: Secondary Definition: Number of CHCs functioning as FRUs X 100 Total number of CHCs proposed during the year

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%

Compile information for 6 months by districts Source of information: MIS (partial)-Proxy Type: Secondary Number of facilities providing RTI/STI services by districts could be compiled
- 45 -

Sr. No.

RCH INDICATOR

Level of achievement

Calculation of the indicator by the State& methodology of data collection in JRM 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 as per protocols X 100 Number of health facilities

Task to be performed in JRM Review

13

M&E Triangulation left out NOTE: THOSE HIGHLIGHTED IN BLUE MAY NOT BE AMENABLE BY REGULAR MIS/FMIS.

- 46 -

Annex. I STATE-WISE TARGETTED & ACTUAL MEDICAL AND PARA-MEDICAL STAFF UNDER RCH-II 2005-06 ACTUAL Sl. No. Others Spl. ANMs/MPWs / PHN/ Staff Lab (BEE/ State Doctors MOs LHVs Nurse Tech. BCC) 1 Rajasthan 32 300 1321 163 178 2 MP 193 328 332ANMs 776 170 3 Chhattisgarh 1231 7451 590 355 125 4 Uttaranchal 40 6 150 6 5 Orissa 50 204 47 16 6 Jharkhand 300 2468 610 1418 7 UP 4 61 2500 470 140 8 Bihar 500 1762 9 Assam 1839 6058 1034 481 10 Arunanchal P. 389 272 31 21 11 Tamil Nadu 510 1170 12 Lakshadweep 7 6 13 Daman & Diu 2 6 14 Maharashtra 55 248 170 60 15 Meghalaya 20 18 250 16 Tripura 150 72 17 Chandigarh(U.T) 21 46 20 34 6 18 Haryana 12 140 169 210 11 19 Punjab 306 3038 6171 1783 780 51 20 Delhi(U.T) 121 874 21 Himachal Pradesh 66 24 420 24 12 BCC 22 Gujarat 193 328 332 776 23 Andhra Pradesh 249 184 24 Kerala 198 126 28 25 Dadar & Nagar Haveli 1 15 8 2 26 Karnataka 4496 500 4309 858 27 Jammu & Kashmir 56 84 84 28 Nagaland 41 116 21 29 Andaman & Nicobar 32 8 30 Pondicherry 4 5 31 Goa 32 Mizoram 8 22 19 138 12 33 Manipur 24 76 22 16 34 Sikkim 6 527 46 35 West Bengal 189 75 75 63 63 -

- 47 -

Annex. II STATE-WISE PROPOSED MEDICAL AND PARA-MEDICAL STAFF UNDER RCH-II 2006-2007 Sl. No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 State Rajasthan MP Chhattisgarh Uttaranchal Orissa Jharkhand UP Bihar WB Maharashtra TN Karnataka Kerala* Andhra Pradesh Haryana J&K Himachal Pradesh Gujarat Punjab* Tripura Sikkim Nagaland Arunachal Pradesh Manipur Assam Mizoram Meghalaya Chandigarh Lakshadweep Pondicherry Goa Daman & Diu Dadar & Nagar Haveli Andman & Nicobar Delhi Spl. Doctors 32 100 40+15 50 300 500+33 189 33 170 100 250 11 66 160 9 4 24 46 9 21 4 2 1 1 150 MOs ANMs/MPWs/LHVs PHN/ Staff Nurse Lab Tech. 300 1321 178 178 314 828 628 s 1231 7451 590 355 6+3 225 130 243 23 60+16 2468 610 1418 60 2500 500 140 1048 75 75 63 63 55 1048 60 360 1170 500 100 566 198 126 28 249 470 712+184 19 641 167 34 56 124 84 84 24 150 24 100 300 80 40 701 315 400 250 150 80 2 44 125 24 21 1 103 32 21 76 22 16 25 855 438 24 80 190 28 25 392 46 30 34 9 7 6 5 1 16 4 4 2 150 15 32 700 8 8 1 2 16

- 48 -

Annex. III(a) STATUS OF CONTRACTUAL APPOINTMENT OF PMU & OTHER CONSULTANTS STATE No. of Districts Mobile Nos. Remarks (if any)

PMU Arrangements State Programme Mgmt. Unit State Programme Manager State Finance Manager State Accounts Manager State Data Assistant

Status Yes No

Name

Address

Tel. Nos

E-mail ID

District Programme Mgmt. Unit District Programme Manager District Accounts Manager District Data Assistant

No. of No. of positions position sanctioned s filled

No. of positions vacant

Bloc level

Positions proposed

Position s filled

Other Consultants (if any) IEC MH CH HR & Admin BCC MIS M&E Advocacy Accountant Data Entry Operator NGO Coordinator Statistical/ Computer Operator Consultant- Procurement/ Infrastructure/ Logistics Admin./ Office Asstts Auditor Architect Civil Engg./ J.Engg. Others ( If any)

Status Proposed Filled

- 49 -

Annex. III(b) DISTRICT-WISE PMU & OTHER CONSULTANTS DETAILS Nam Mobile Tel. E-mail District- I Status e Address Nos. Nos ID Remarks(if any) District Programme Mgmt. Unit Yes No District Programme Manager District Accounts Manager District Data Assistant Nam e Address Mobile Nos. Tel. Nos E-mail ID Remarks(if any)

District- II Status District Programme Mgmt. Unit Yes No District Programme Manager District Accounts Manager District Data Assistant

District- III Status District Programme Mgmt. Unit Yes No District Programme Manager District Accounts Manager District Data Assistant

Nam e Address

Mobile Nos.

Tel. Nos

E-mail ID Remarks(if any)

District- IV Status District Programme Mgmt. Unit Yes No District Programme Manager District Accounts Manager District Data Assistant

Nam e Address

Mobile Nos.

Tel. Nos

E-mail ID Remarks(if any)

* To be filled in the same format for all districts

- 50 -

Annex. IV INFRASTRCUTRE UPGRADATION / MAINTAINANCE 2006-07 (Repair & Renovation) State Name
S. No Facility Identified No. of Renovation s proposed in the PIP 2005-06 No. Renovations completed 2005-06 No. of Renovations proposed in the PIP 200607 Renovation under way Renovation completed Com ment

1.

Sub Centers

2.

PHCs

3.

CHCs

4.

District Hospitals

- 51 -

Annex. V DETAILS OF THE TRAINING PROGRAMMES FOR SPMUs/ DPMUs 2006-2007 Dates of Training & Duration Venue of Training States Involved Districts Involved Category of Participants Total No. of participant s Training Curriculum prepared (enclosed) Name & Address of the training Cocoordinator

No. & Level of State Govt. officials 1 2 3 4 5

No. of SIHFW Faculty & Participants 6

No. of PMU Officials (State & Districts)/ Other Consultants 7

10

- 52 -

Annex. VI Format for showing Annual Progress on the Performance Indicator as per National RCH-II PIP Name of the State: Name of the Mission Director: Address: Tel. No. email ID: Year : 2005-06
S.no. Indicator 1 Contraceptive Prevalence Rate * Numerator Denominator Number of listed eligible Total number of eligible couples using one or couples listed other modern method of contraception Value

Eligible couples using Number of listed eligible Total number of eligible any spacing method for couples using one or couples sampled/listed more than 6 months * other spacing methods <30 years for more than 6 months Pregnant women receiving 100 or more IFA tablets * Number of women who Number of women who delivered during past delivered during past one one year receiving 100 year or more IFA tablets

Deliveries conducted by Number of women who Number of women skilled providers * delivered during past delivered during past one one year by skilled year providers % contributed by SC/ST Number of deliveries Total no. of deliveries populations among reported by public health reported by public health deliveries reported by facilities pertaining to facilities public facilities SC/ST population compared to population in state 12-23 months children Number of listed 12-23 Number of 12-23 months fully immunized * months children fully children listed immunized % achievement of planned measles coverage among SC/ST population Zero free polio status achieved since * Children suffering from diarrhea given ORS * No. of SC/ST cases covered for measles Total no. of SC/ST cases planned to be covered for measles

No of districts reporting Number of districts with no polio cases non polio AFP rate more than one Number of children who Number of Children who suffered from diarrhea suffered from diarrhea during past two weeks during past two weeks and received ORS

- 53 -

S.no.

Indicator

Numerator

Denominator

Value

10 Mothers and newborn visited as per schedule within 2 weeks of delivery by a trained community level health provider/AWW or health staff (ANM/Nurse/Doctor) * 11 % of districts not having at least one month stocks of (a) Measles vaccine, (b) Oral Contraceptive PIlls and (c) Gloves

Number of Mothers and Number of mothers newborn visited as per delivered during past one schedule within 2 weeks year of delivery by a trained community level health provider/AWW or health Staff (ANM/Nurse/Doctor) No. of Districts not having stocks of (a) Measles vaccine, (b) Oral Contraceptive Pills and (c) Gloves Total no. of Districts

12 Twenty-four hour PHCs Number of 24 hr. PHCs Number of 24 hr. PHCs conducting at least 10 conducting 10 or more reporting deliveries in a month deliveries in a month 13 Upgraded FRUs offering Number of upgraded 24 hr. emergency FRUs offering 24 hr. obstetric care emergency obstetric care 14 % of ANM positions filled No. of ANM's in position 15 % of states and districts No. of DPM in position having full time programme manager for RCH with financial and administratie power delegated 16 % of allocated funds for Funds disbursed to the year disbursed Districts during the year Number of FRUs surveyed/ reporting No. of ANM's sanctioned No. of DPM Santioned

Funds available with the society during the year

* These indicators will also be covered under Mid Term and End Line Surveys.

- 54 -

ANNEX 2 RCH FLEXI POOL (PART A) FUNDS RELEASED AND EXPENDITURE

RCH FLEXI POOL (PART A) FUNDS RELEASED AND EXPENDITURE

Rs. crores unless otherwise specified
S. No. A 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 B 20 21 22 23 24 25 26 27 C 28 29 30 31 32 33 34 35 States/UTs Approved Funds PIP Released % 05-06 06 07 Expenditure Unspent Exp as % Funds Exp incurred Reported Amount of Funds Released during the first (March Released Apr - Jun 06 quarter of FY 06) 2006-07

NON-EAG States Andhra Goa Gujarat Haryana Himachal J&K Karnataka Kerala Maharashtra Punjab Tamil Nadu West Bengal A&N Islands Chandigarh D&N Haveli Daman & Diu Delhi Lakshadweep Pondicherry TOTAL EAG States Bihar Jharkhand MP Chhattisgarh Orissa Rajasthan UP Uttaranchal TOTAL N.E. States Arunachal Assam Manipur Meghalaya Mizoram Nagaland Sikkim Tripura TOTAL GRAND TOTAL

90.50 1.50 60.50 25.00 7.50 12.00 63.00 38.00 115.50 29.00 74.00 95.50 0.50 1.00 0.50 0.50 16.50 0.50 1.00 632.50 128.50 42.00 93.50 32.50 57.00 87.50 257.50 13.00 711.50 7.35 116.05 11.93 9.00 13.57 10.36 1.82 9.67 179.75 1523.75

58.85 1.05 33.83 11.42 5.00 6.05 28.80 21.44 52.8 17.42 61.38 59.83 0.44 0.74 0.35 0.23 7.27 0.12 0.87 367.89 29.38 40.6 66.2 27.46 40.5 40 169.72 7.46 421.32 7.35 64.91 7.43 4.5 11.82 6.61 1 6 109.62 898.83

65 70 56 46 67 50 46 56 46 60 83 63 88 74 70 46 44 24 87 58 23 97 71 84 71 46 66 57 59 100 56 62 50 87 64 55 62 61 59

51.33 0.28 22.12 8.06 3.21 1.71 5.24 4.82 15.98 5.97 52.49 3.18 0.32 0.64 0.17 0.43 1.65 0.14 0.92 178.66 4.37 18.21 25.3 9.19 36.52 22.72 48.14 4.28 168.73 4.65 28.69 0.64 0.83 8.78 0.01 1.03 2.02 46.65 394.04

7.52 0.77 11.71 3.36 1.79 4.34 23.56 16.62 36.82 11.45 8.89 56.65 0.12 0.1 0.18 -0.2 5.62 -0.02 -0.05 189.23 25.01 22.39 40.9 18.27 3.98 17.28 121.58 3.18 252.59 2.7 36.22 6.79 3.67 3.04 6.6 -0.03 3.98 62.97 504.79

87% 27% 65% 71% 64% 28% 18% 22% 30% 34% 86% 5% 73% 86% 49% 187% 23% 117% 106% 49% 15% 45% 38% 33% 90% 57% 28% 57% 40% 63% 44% 9% 18% 74% 0% 103% 34% 43% 44%

94.09 0.46 49.35 21.73 6.19 6.76 0 17.69 78.75 14.2 0 30.67 0.49 0.82 0.3 0.41 0 0.15 0 322.06 0 14.43 2.88 0 49.57 69.61 0.01 9.11 145.61 3.2 21.84 0 0 0 0 1.88 6.19 153.67 621.34

24.74 0.06 3.39 2.84 3.64 0.26 2.28 1.54 4.78 1.84 1.19 0.23 0.12 0.04 0.04 0.06 0.02 0.13 47.2

3.74 6.69 1.99 4.77 6.08 0.15 23.42 1.88 1.31 0.39 1.03 0.4 0.18 0.39 5.58 76.20

- 55 -

ANNEX 3 METHODOLOGY FOR RANKING OF STATES

METHODOLOGY FOR RANKING OF STATES BACKGROUND The purpose of ranking of performance of states on RCHII 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, 5 indicators (see below) have been selected largely on the basis of data availability and equal weightage has been given to each indicator. Further the ranking has been confined only to the 18 high focus states. Over a period of time, the methodology would be refined in terms of e.g. introducing other indicators and perhaps differentiating between the large and small states. Although the present system of ranking has several limitations, it does provide some indication of a states relative performance. INDICATORS The 5 indicators used in this exercise have been selected largely from amongst the RCH process indicators specified in the NPIP. The source of data for all the indicators is the respective state (presentations made in Delhi), except for utilisation of funds, where MoHFW data has been used. The cut off percentage for each indicator takes into consideration delays in e.g. dissemination of some guidelines and release of funds. Each indicator has been given a weight of 2. A score of 0 is also given where information on the particular indicator is not available from the State presentations or the MOHFW programme divisions. 1. At least 50% of 24 hr PHCs conducting minimum 10 deliveries per month If the indicator is met, a score of 1 is given. For 30-49%, the score is 0.5, and for less than 30%, the score is 0. 2. At least 50% DPMUs in place and trained There are limitations to the data provided by states on this indicator. Some states have not shown the training status and further the data is aggregated across districts. A state gets a score of 1 ( if the indicator is met) or 0. 3. At least 50% DAPs available JRM field visits have shown that while States are showing good progress on development of District Action Plans, a strict consultative process with all stakeholders is not necessarily being followed. Additionally, the information provided on DAPs does not differentiate between the RCH II DAPs prepared in 05-06 and the NRHM DAPs currently under preparation. Nevertheless, the score is based on numbers i.e. if 50% of DAPs are reported to be available then the state is given a score of 1. 4. At least 80% ANMs in place If the indicator is met, a score of 1 is given; otherwise the score is 0.

- 56 -

5. At least 30% of funds utilized It has been observed that the figures provided in the State presentations and those available with FMG are not consistent. For this ranking, the FMG data has been used. If the indicator is met, the score is 1; for less than 30%, the score is 0. RANKING AND GRADE The states have been ranked based on the overall score from the five indicators mentioned above. A further grading has been done based on the overall score as follows: 9-10: 6 8: 4-5: < 3: A B C D

- 57 -

ANNEX 4 IMPLEMENTATION STATUS OF PRIORITY ACTIONS AGREED TO IN THE FIRST JRM

IMPLEMENTATION STATUS OF PRIORITY ACTIONS AGREED TO IN THE FIRST JRM

Issue Governance/ Programme management/ convergence Actions Finalise the NRHM implementation framework and clarify the procedures and regulations in order to ensure that there will be the desired convergence by 2007. Fill the remaining positions stipulated in the PIPs for the SPMUs and DPMUs, and complete the orientation training Responsible body MOHFW Time frame 31 March 2006 Action Taken / Current Status NRHM implementation framework approved . Procedures and regulations yet to be clarified.

States / districts

31 March 2006

Delayed. UP has made no progress on establishing SPMU/DPMUs, while the percentage of DPMU positions filled in Jharkhand, Bihar, Chhattisgarh and MP varies from 53% to 74%. Staff turnover is becoming an area of concern. All districts were expected to have plans by 2007. With the emphasis on integrated district plans under NRHM, this goal is likely to be met.

Finalise DAPs so that resources can be appropriately allocated to the most needy areas Disseminate support team names & contact details to each State Provide additional funds for RKS if necessary, to make them more functional Address convergence more comprehensively Financial management Though the Ministry mentioned that at the start of the year, only 1/6th of the proposed budget is allowed to be released as vote on account amount till budget is approved. However, it was suggested that the Ministry may take up the matter of release of 75% funds at start of the financial year to minimise delays in further disbursement Provide more clarity on FM procedures at all levels

States / districts

31 March 2006

MOHFW

31 March 2006 April 2006

State governments States / districts MOHFW

July 2006

Satisfactory. Based on provisional UCs received for 05-06, 75% ( or 66%) of approved PIP amounts released to States/UTs for 2006-07 (after adjusting the unspent balances)

MOHFW/ States

Considerable progress. Model guidelines at State and District levels under RCH-II generic guidelines circulated earlier. Guidelines have been prepared for sub-

Issue

Actions

Responsible body

Time frame

Action Taken / Current Status district levels. Dissemination through workshops held in April and September, 06. Finance & Accounts Manual and revised chart of accounts available on ministrys website. Functionaries of all the erstwhile EAG states have been provided training. Some States has taken up district level training, and the remaining will take it up. Accounting system in Tally has been designed. To be demonstrated to a few states.

Provisional UCs to be submitted for 1st year expenditure for release of 2nd year funds Provide overview of funds allocated, received, utilised & remaining

States

Implemented. Provisional UCs for FY 2005-06 received from all 35 States/UTs. Provided by MOHFW for 0506 and for about 30 states/UTs for first quarter of 06-07. System in place. However data provided by states is inconsistent with MOHFW figures, even on items such as funds transferred to states. June 2006 Completed.

States

Maternal Health

Organise TA for select HF states to develop clear plan for making existing facilities functional, focusing first on those needing only minimal additional inputs and on those in the most needy areas. SA of GNM training centres in the States facing shortages for staff nurses and develop a road map Revision of Drug kits as per new service delivery guidelines Provide more clarity on the JSY scheme so that available funds are utilised: The FAQ booklet may be revised & published

MH Division

Respective States

June 2006

MH Division MH Division

March 2006 March 2006

Modified Drug List developed for SBA. JSY modified to make it easily accessible to poor in the 10 low performing States. However, awareness about the

Issue

Actions

Responsible body

Time frame

Action Taken / Current Status scheme is still poor. There is low visibility and lack of clarity among lower level functionaries MH Division is working out several strategies with IEC Division. FAQ booklet not revised.

Child Health

Finalise and dissemination of operational guidelines for IMNCI to be used by the State and District Programme managers Develop a strategy for engaging private providers to enable them using IMNCI protocols Organise technical assistance to the select high focussed States for developing microplans under multi-year immunisation plan

CH Division

April 2006

Guidelines for IMNCI have been finalised and disseminated.

CH Division

June 2006

Not developed.

CH Division / States

June 2006

TA not organised.

Family Planning

Finalisation and dissemination of manual for quality assurance in sterilisation. Develop a SOP manual for RCH camps Mass-media category promotion for ECPs

RSS Division

April 2006

Quality Assurance Manual has been updated and is being printed with UNFPA support. SOP manual for Sterilisation in Camps is under process. Newer spots on EC prepared and disseminated for mass media publicity. Special issue on EC taken out in IMA journal in Sept06. Dissemination through Contraceptive Update trainings. Information dissemination to Chemists through their associations.

RSS Division RSS / IEC Division

May 2006 June 2006

Revision of existing contraceptive service-delivery guidelines and sterilisation standards.

RSS Division

August 2006

Standards on Sterilisation updated, to be printed by UNFPA. Guidelines on IUD, OCs, ECs to be revised in 06-07 under WHO biennium.

Issue ARSH

Actions Finalisation and dissemination of implementation guide for operationalising ARSH strategy Finalise training modules for Medical Officers and ANMs and share with States

Responsible body IEC Division

Time frame April 2006

Action Taken / Current Status Implementation guide has been finalised and disseminated. Training packages for Medical Officers and LHVs/ANMs have been finalised and disseminated. Training Plans prepared by the states are integral to the comprehensive HR Policy.

IEC Division

April 2006

Trainings

Develop HR policies including training.

States

August 2006

Comprehensive training plans to be shared by the States Assessment of PDC Programme

States

33 States and UTs have submitted their CTPs (except Meghalaya and Sikkim). April 2006 After completion of three batches of the Professional Development Course (PDC) at NIHFW, an evaluation of the training course was done by Tata Institute of Social Science, Mumbai, which clearly indicated the usefulness of this course. An independent evaluation will be done shortly to assess the effectiveness of this course.

Training Division

Commissioning a Situational Assessment Study of Training Management in health sector Develop and dissemination of plans for strengthening training management based on the recommendations of above study BCC Develop and dissemination of operational guidelines for decentralised BCC strategy addressing NRHM issues Organise technical assistance for capacity building of State counterparts to plan, implement and monitor BCC plans Innovations Initiate pilots and actions on PPP and other innovations in the State PIPs.

Training Division IEC Division

June 2006

Not carried out

September 2006

Not carried out

IEC Division / States

June 2006

Not developed. TA required.

IEC Division / States

July 2006

Regional workshops planned for building States capacity. TA yet to be organised.

States

July 2006

Issue Equity & Access/ Vulnerable Groups

Actions Situational Analysis Map key indicators such as % of underweight children, Institutional Delivery immunisation (as in RHS), disaggregated as far as possible by sex, SC/ST, District and Block to identify who are the most vulnerable, where they are and what their specific/additional requirements are. Map existing human, financial and infrastructure resource allocation. This will indicate the priority areas and vulnerable groups This may require TA Ensure that ASHA is well linked to the SC and PHC, and fully supported by the health staff at those facilities Include urban health and tribal health plans in the overall PIP so that approval is obtained simultaneously for all Document success stories in posting staff to remote and underserved areas and share with other States

Responsible body MOHFW / M&E Division

Time frame On-going

Action Taken / Current Status

States / districts

States

Included in PIPs for 06-07. Simultaneous approval given.

MOHFW/ Director, Area Projects

M&E/ focus on outcomes

Finalization of MIS format from State to centre level

M&E Division

April 2006

MIES Format developed and sent to State Governments in August, 2006 Guidelines for MIES Format to be prepared with Technical Assistance of UNFPA (to contain information on use of MIES data) likely date within December, 2006 .

Preparatory work for piloting of QA.

May 2006

Monitoring tools and check lists for QA have been finalized and QA Operational Manual has been prepared. Six States have been identified for piloting of QA UP, Uttaranchal, West Bengal, Assam,

Issue

Actions

Responsible body

Time frame

Action Taken / Current Status Maharashtra, and Karnataka (1 Distt. each, 2 in UP). Agencies have been identified for piloting PATH, Population Council and Engender Health. UNFPA to support funding for piloting in 3 states, while other DPs may support the remaining States.

Finalization of Programme management assessment methodology and manual.

July 2006

Study by IIM-A to have been completed in collaboration with SIHFW, Jaipur in July 2006 Gujarat study completed, Rajasthan study incomplete. It is proposed to use the results from the Gujarat study and conduct a pilot involving 3 EAG & 2 NonEAG States in December 2006. The tools may then be refined before up-scaling country-wide after feedback .

Development of methodologies for community monitoring and triangulation of data NFHS-III Report, Table, Formats etc. Completion of Field Work of NFHS-III Data entry and Processing M&E Division

March 2007

Not developed. M&E Division does not have technical capacity to develop the system. TA required.

April 2006 June 2006 Completed.

Oct 2006

Results of 5 states released in August 2006 (Chhattisgarh, Gujarat, Orissa, Maharashtra, and Punjab). Results from remaining States to be released in October 2006.

A few summary results, all India level only National & State Report & Dissemination

Nov 2006

Start by March 2007

Issue DLHS-III

Actions Preparatory work (Administrative, Technical and Questionnaire finalisation)

Responsible body M&E Division

Time frame May 2006

Action Taken / Current Status Coverage, Survey design and sample size per district decided . Evaluation of the technical and final proposal of the survey completed. Total cost of the survey examined and additional fund requirement projected. Administrative approval granted.

Engagement of Field Organization Training of Trainers (1st Phase) Field work Phase I Training of Trainers 2nd Phase Field work in remaining districts Dissemination of All India Report Training/ BCC/ NGOs Others Prepare a comprehensive training plan TA Set up State facilitation teams (GoI/DP/States) for enhanced support to EAG & NE States on a continuous basis (till NHSRC is set up) States MOHFW

Aug 2006 Sep 2006 Oct 2006-Feb 2007 Jan 2007 March 2007 June 2007 Nov 2007 To commence in January 2007.

April 2006

ANNEX 5 PRIORITY ACTIONS AGREED TO IN THE SECOND JRM

PRIORITY ACTIONS AGREED TO IN THE SECOND JRM Following are the agreed key actions to be implemented by the next JRM: 1. 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. 2. 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. 3. 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. 4. Initiate regional dissemination of technical guidelines of the program to state managers at state and district levels. 5. Finalize the IMEP and initiate regional dissemination of this to all states and districts. 6. Set up programme management support arrangements for UP and the NE States. 7. 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. The specific actions to be undertaken by the MOHFW Divisions and States are:
Issue Governance/ Programme Management Actions 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. HRD strategy review for state and district program management units in HP, J&K and Assam. 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. 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 National protocols for management of RTIs/STIs along with training guidelines and material will be DC Division/ M&E Division Responsible body DC Division Time frame December 31, 2006

December 31, 2006 April 2007

NHSRC/MH Division

January 2007

MH Division

January 2007

Issue

Actions finalized and shared with workshops and state visits. states through

Responsible body

Time frame

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. NRHM focus states to prepare IEC plans to create increased awareness about the JSY, especially among members of local bodies and communitybased organizations. 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. Child Health Evolve strategy to increase training institutions for IMNCI at national and regional levels including greater involvement of institutions from NGO and private sector. Finalize guidelines for Home Based New Born Care and disseminate to the states. Finalize policies on Micronutrients and extended authorizations for use of Gentamycin and Cotrimoxazole Family Planning Finalize a strategy and plan for enhancing access to spacing methods. Finalize Standard Operating Procedures for organizing FP camps incorporating appropriate protocols for Quality Assurance. 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. Pilots for PPP in FP service provision including injectable contraceptives are established.

MH Division

December 2006

States NRHM focus States

March 2007 December 2006

MH Division, Training Division, Advisor (Nursing)

March 2007

Child Health Division

March 2007

Child Health Division

December 2006 December 2006

RSS Division

December 2006 December 2006 January 2007

RSS Division

December 2006

Issue Training

Actions Assess the infrastructure and HR needs of SIHFWs, CTIs, and RRCs. All States to review their CTPs and PIPs to ensure rationalized trainings and connect them to service provision A section on supportive supervision to be incorporated into all training modules and guidelines for skills post-training skill assessment finalized.

Responsible body Training Division States

Time frame January 31, 2007 June 2007

Training Division/ NIHFW

January 31, 2007

Innovations in service delivery

Document and disseminate best practices on PPP. Facilitate availability of contractual technical assistance to States, and also provide support for M&E. Formats for evaluating on-going innovation to be ready for use. Assessment report on the progress of the NGO scheme to be provided.

IEC / with other program divisions NHSRC/ SHSRC M&E Division NGO Division IEC Division

January 31, 2008 January 2007

June 2007 By next JRM January 31, 2007 March 31, 2007 and May 31, 2007

Demand Creation

BCC unit at the national level to be fully staffed with clear roles, responsibilities and deliverables for the staff. 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. Mechanism to support states in development of a comprehensive and integrated BCC strategy. Organise TA for capacity building of state counterparts to plan, implement and monitor BCC activities. Strengthen the ASHA/AWW/ANM training with interpersonal communication skills to adequately address patient concerns and empower patient decision-making.

Erstwhile EAG and NE states, J&K and HP

IEC Division

January 31, 2007 December 2006 June 2007

Monitoring and Evaluation

Reactivate the M&E Working Group Develop a pilot proposal for community based monitoring and prepare a short list of appropriate institutions for its implementation. TA to be provided.

M&E Division M&E Division/ NHSRC

October 31, 2006, January 31, 2007 November 2006.

Issue

Actions TA to be provided for developing a framework for triangulation. Organize series of state level workshops to train state and district level staff in the reporting information in the new monitoring format. Develop TOR for independent management review of process indicators including rapid facility assessments. Initiate the process for organizing regional workshops with State / District PMUs to disseminate the M&E framework and the revised MIES format

Responsible body

Time frame November 2006 January 31, 2007 October 31, 2006 January 2007

Procurement

Confirm procurement arrangements with UN agencies for FY 2006. Share draft TOR and RFP for recruitment of procurement agent with development partners. 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

October 20, 2006 November 31, 2006 November 1, 2006

Financial Management

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. Share FMRs for six-month period ending on September 30, 2006 and MOHFW will share the FMRs with pooling partners in the agreed format. Establish a system for quarterly financial and procurement reporting of central activities from the technical units to FM. Develop process of a structured management audit with specific TOR and outsource it to complement the review by FMG.

FMG and States (contingent upon States submission)

November 15, 2006

November 1, 2006 FMG Immediately

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 6 STATE REPORTS

RCH II: FINDINGS OF 2ND JRM ANDHRA PRADESH Impressive range of innovative strategies are being implemented to meet RCHII goals coupled with relatively better health seeking behaviour augurs well for the future. Funds utilization in 05-06 is an impressive 87%. The major challenge for Andhra Pradesh is to upgrade the quality of services and scale up the numbers of Skilled Birth Attendants (SBAs). In addition, effective convergences plan with eg WCD, PRIs, medical colleges etc. would have far reaching effects. . Financial progress (2005-06) Allocation Release Expenditure Expenditure/ Release

Rs. 90.50 crs Rs. 58.85 crs Rs. 51.33 crs 87 %

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS

GOVERNANCE SPMU and DPMU fully functional State Health Mission constituted Advertisement under way for recruitment Expedite the process of recruitment. of ANMs (2nd ANM under NRHM) Doctors for Mobile Medical Unit yet to be Need to explore possibilities of NGOs recruited providing doctors for MMUs No ASHA scheme for the non tribal districts of the state Govt. has approved the state up of sub district management unit Specialists not always available at FRUs. Try to provide urban health workers in the non-tribal areas. Need to set up the unit as soon as possible Need to rationalize staff all across the state TECHNICAL INTERVENTIONS New-Born Care Kits for LBW infants; Ensure that the beneficiary is instructed tender issued for 6.5 lakh units about the proper use of the kit. State of the Art Cold-Chain/Vaccine Stores in all districts built State has a history high death rates due to hysterectomy Health days conducted regularly Ensure proper maintenance. Strengthen IEC State needs to take regulatory decision to tackle deaths due to hysterectomy. Make sure that health days are of high quality through proper monitoring.

- 69 -

ACHIEVEMENTS/ OBSERVATIONS Blood Banks (16) and Blood Storage Centres (89) being established in the CEmONC centres with IRCS, AP Branch; Orders placed for major and minor equipment 147 Neonatal Intensive Care Units (NICU) have been set up in District, Subdistrict Hospitals and selected CHCs

SUGGESTED ACTIONS State could enter into PPP with The Red Cross for provision of blood/ management of blood banks.

INFRASTRUCTURE DEVELOPMENT

Need to look into the quality of care at NICU

TRAINING/ IEC/ NGO INVOLVEMENT Establishment of Village Level Health and Sanitation Committee, under joint signature of Secretary, Rural Dev., WCD, Health & PHED. Training in MTP by MVA technique & Medical Abortion outsourced with help of IPAS Pilot referral transport scheme through PPP in one block of each district under consideration Training of Lady MBBS doctors of CEmONC centers in Ob/Gyn depts of Dt. Headquarters Hospitals 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 Need to put more effort on IEC of Emergency contraceptive pills, especially at community level

Low use of emergency contraceptive pills

EQUITY AND ACCESS Rural Emergency Health Transport Services scheme: operationalized under PPP thro NGOs 8 lakh free bus passes given to SC/ST & BPL pregnant women in rural areas to enable them to get least one ANC checkup with a qualified medical doctor Young Infant Health Assurance Scheme Part A: Voucher scheme for Emergency OP care and Part B: Emergency In-patient Care thro PPP; both for SC/ST and BPL infants < 2 months age with < 1500 gms BW Mobile Medical Units are deployed in tribal areas

- 70 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

Health Melas in tribal areas M&E AND TA REQUIREMENTS Base-Line survey commissioned; Midterm Evaluation proposed in 2007-08 State to specifically provide documentary evidence for achievement of core 13 indicators as specified in Enclosure 4 of the JRM Process Manual. OTHERS MOU entered with Emergency Management & Research Institute (EMRI, an NGO sponsored by Satyam Computers Ltd); EMRI to run emergency ambulances Free of Charges with a single toll-free number in the entire state Chaduvula Thalli scheme cash stipends to BPL girls; implementation thro Womens SHGs in villages.

- 71 -

RCH II: FINDINGS OF 2ND JRM ARUNACHAL PRADESH Arunachal Pradesh has made rapid progress since the last JRM. In spite of several bottlenecks like lack of infrastructure, manpower, technical know how, and remote areas the State has made sincere attempts at decentralization specially at the district level. The initiative of innovative partnerships with NGOs is praiseworthy. Institutional strengthening has been taken up sincerely. In the absence of skilled personnel, and proper management, quality of interventions has not been up to the mark .Program management system need to focus on outcome and impact on key indicators. Capacity building of personnel in several technical areas needs to be addressed on a priority basis. The discrepancy regarding the fund flow and utilization with the GOI needs to be resolved at the earliest Financial progress ( 05-06) Allocation Release Expenditure Expenditure/ Release Rs. 7.35 Crores Rs. 7.35 Crores Rs.4.65 Crores 63%%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE State Health Mission and State The DPMU needs to be in place Health Society constituted under NRHM and proper planning needs to be done for effective interventions at the district level. 16 District Health Societies constituted. Bye-laws of the State Health Society formulated At the State level recruitment of three positions has been completed. However at the district level units , only 32 out of 48 sanctioned positions have been filled . Induction training done for Managers in RRC-NE FINANCIAL MANAGEMENT Fund released to 16 districts for JSY Streamline fund flow to the districts for effective program implementation. Flow flow and fund availability is a Speed up the procurement of concern at the district level expenditure statements from districts (communication problems) TECHNICAL INTERVENTIONS 1615 ASHAs have been selected but Prioritize training of ASHA in home not trained so far. based delivery services and link them to health facilities Sensitize MOs and ANMs to assist ASHA

- 72 -

ACHIEVEMENTS/ OBSERVATIONS Of 31 CHC , 16 have been upgraded Orientation training of Depot holder and Link Worker/ (ASHA) , PRI, NGO, PHED and SWWCDhas been completed TOT has been completed for IMNCI, and SBA Training of one batch of IMNCI completed ( 25 MOs,55 ANMs)

SUGGESTED ACTIONS Provide managerial services at CHC and PHCs

Plan for IMNCI strategically. Undertake phase wise training of limited batches for qualitative outcome . Hospital waste management unit not Initiate training of health functional due to delay in training of functionaries at the earliest to make health personnel hospital waste management unit functional TRAINING/ IEC/ NGO INVOLVEMENT 16 PHCs managed by NGOs. Out Comprehensive training plan and reach programme done by NGOs. calendar to be prepared with prioritization of key trainings Project prepared for PPP for 16 PHCs 21 RCH camps have been conducted with the active support and participation of 7 NGOs Training plans prepared for PRI functionaries EQUITY AND ACCESS Urban health programs initiated in Naharlagun and Pasighat Improve access to basic services in remote areas through ARMY-State Communities lack access to basic partnership health care in remote areas M&E AND TA REQUIREMENTS Technical assistance required for RRC to support State in capacity M&E, SBA building for monitoring in outreach areas Computerization and LAN connectivity required in all districts. OTHER ISSUES Lack of adequate manpower to man health facilities Prioritize identification and appointment of skilled manpower

- 73 -

RCH II: FINDINGS OF 2ND JRM ASSAM Assam has shown a perceptible improvement since the last JRM. However, the focus is largely on the state capital/ adjoining districts. Financial transparency and accountability needs to be ensured at all administrative levels. The State has the scope to improve its performance through strategic planning and involvement of various actors like administrative heads, civil society and community leaders at various levels. Financial progress ( 05-06) Allocation Release Expenditure Expenditure/ Release Rs.116.05 crores Rs.64.91 crores Rs.28.69 crores 44%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE At the state level, out of the 13 Appointment of all staff and their ( including 4 for SPMU) sanctioned training should be fast tracked. In the positions, 7 have been filled. The status of case of accounts staff , consider DPMUs has shown considerable appointment of commerce improvement in the last six months. So far, graduates and provide in depth 23 programme managers and 17 Accounts training. managers have been recruited in the 23 All SPMU/DPMU staff should be DPMUs. Particularly difficult to get trained in accordance with the accounts staff and data assistants in programme developed by NIHFW. spite of advertisements in the local dailies A round of induction has been completed for the new team members District Health Mission constituted & notified in Dec2005 in all districts District Health Societies registered in 23 districts.

FINANCIAL MANAGEMENT Tracking of funds is difficult leading As above to poor accountability in the financial management system TECHNICAL INTERVENTIONS There are 30 functional Ensure operationalization of FRUs.Twenty more will be taken up for FRUs/Cemoc/Bemoc in a upgradation coordinated manner

- 74 -

ACHIEVEMENTS/ OBSERVATIONS 50 BPHCs have been identified as 24 X 7 PHCs & civil construction is underway Repair and renovation of 149 BPHCs in progress Training of doctors for IMNCI-11 National trainers trained at Delhi, 23 State TOT, 2 batches of ANM at Dibrugarh Medical college !00% JSY funds released to districts Rogi Kalyan Samitis have started collecting money ( Rs. 3 lakhs in Golaghat district)

SUGGESTED ACTIONS

RKSs should be made fully functional Community to become active participants Intensive monitoring of RKS required TRAINING/ IEC/ NGO INVOLVEMENT Training of 8808 ASHAs completed in Popularize ASHA through 11 districts sectoral meetings with Sarpanchs and Gram Sabha Focus on monitoring of ASHA Sensitisation of PRIs regarding RCH carried out through training (4058 PRIs trained in SIRD) Health Day organized regularly. Awareness provided on maternal and child health. Extensive IEC activities being carried out in the State level especially JSY Ensure quality of health day through effective monitoring. Health day should be utilized to disseminate IEC messages Since tobacco and betel nut consumption by women is common, awareness and anti-tobacco campaign needs to be aggressively launched. Utilize the services of local TV channels to disseminate messages to the community . Feedback on BCC received BCC activities should be evaluated for impact/ behaviour change. Selection of MNGO is slow and should be completed by December

!2 MNGOs selected in 14 districts

EQUITY AND ACCESS Lack of data on vulnerable groups in Special plans for remote areas in rural and urban slum areas Karbi Anglong and NC Hills district

- 75 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

M&E AND TA REQUIREMENTS Regular monitoring done at the state level. Monthly monitoring of the programme with Joint Directors. One round of reviews held with the District Magistrates in Aug 2006.. The second review with the District Magistrates is scheduled for 5th October

Non-availability of data. Available data vague and inconsistent. Old formats are in use. Health personnel not comfortable with computerized HMIS.

Verify and collect data from ANM ( for IEC and MIS ) in monthly meetings . PHCs collate the data at their end. RRC to introduce and orient user groups on new formats in block s/ districts

OTHER ISSUES Absence of well equipped hospitals and Explore the scope of an Armytraining facilities in the State. Health department partnership for better access of community to hospital facilities. The RRC to take the initiative to facilitate a productive interface of the Army and the State. Prioritize training needs urgently Special strategies required for VGs

- 76 -

RCH II: FINDINGS OF 2ND JRM BIHAR There has been a paradigm shift in Bihars approach to implementation of RCHII. The states performance is particularly impressive given the historical context. In order to quickly make a difference on the ground the state has attempted to rationalise staff , conceived and rapidly implemented a number of innovative ideas eg PPP for a host of services including vaccine delivery through vaccine carriers and hospital maintainance; NGOs to provide family planning services and monitoring of patient load at key facilities. Simultaneously, steps are underway to improve infrastructure and skills of health functionaries. For long term sustainability of the programme there is a need to strengthen institutional structures and effectively deploy all departmental human resources. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 128.50 Crores Rs. 29.38 Crores Rs. 4.37 Crores 15 %

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE State Health Mission constituted. State to closely monitor recruitment State and Districts Health Societies and effective deployment of DPMU staff. registered and made functional. SPMU Need to ensure clarity of roles and staff recruited. Decentralised recruitment reporting relationships and identify steps of DPMUs in progress. for effective integration of DPMU staff into the health department. Manpower transferred from APHCs to PHCs for ensuring 24 X 7 functioning of PHCs. DCs delegated powers to transfer MOs within the district. This is a tremendous step forward. ANMs could also be delegated powers for utilising untied funds at SHCs.

TECHNICAL INTERVENTIONS District hospitals not providing An incentive mechanism needs to be mandated services, due to shortage of developed for them to keep them Mos, who are currently overloaded. motivated. Mobile medical vans providing services in 4 districts Mobile boat clinics could be considered for villages situated on riverbanks.

- 77 -

ACHIEVEMENTS/ OBSERVATIONS Construction/ upgradation of health facilities in progress. Common biomedical waste plant set up at Patna. Tender being floated for other big cities.

SUGGESTED ACTIONS Institutions to be made eco friendly through water harvesting structures and use of local material, focus on utility. Construction and maintainance of toilets for inpatients as well as visitors at health facilities to be given focus.

Availability of manpower and availability of drugs, etc. need to be synchronised Outbreak of Kala Azar disease needs to be mapped and tackled. TRAINING/ IEC/ NGO INVOLVEMENT Induction training of DPMUs along SIHFW will not have the necessary with DoHFW officials of 21 districts capacity. SIHFW to be strengthened/ completed. SIHFW is the nodal agency. operationalised.

Lack of trained manpower at various levels. Poor knowledge levels of ANMs.

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

Comprehensive training plan for 2006-07 developed and sent to GOI TOT for SBA, IMNCI in progress. IMNCI training initiated in 6 districts. Strengthening of ANMTCs with help of UNICEF in progress INNOVATIONS APHCs contracted out to NGOs. The innovative schemes need to be evaluated. Civil surgeon allowed to purchase drugs. Public disclosure of drugs. DC appoints a person from his office to inspect health facilities. Emergency medical services coordinated through district level control rooms. Hospital maintenance outsourced. EQUITY AND ACCESS Pathological tests through PPP in RKS should subsidise/ provide free district hospitals. Pre determined rates tests for BPL patients for tests. Selection and training of ASHAs well underway Incentives to be paid to ASHAs for their services

- 78 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

M&E AND TA REQUIREMENTS Data centre for monitoring of PHCs 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)

NB: Bihar has taken action on all key issues flagged by the 1st JRM

- 79 -

Progress on 13 identified process indicators (as provided by Bihar): Sr. RCH indicator Level of achievement no. 1. % of ANM positions filled 435 ANMs on per session basis engaged for immunization. Adv. For 1190 ANMs scheduled this week 2. a. % of districts having full time programme managers 60.53% for RCH b. administrative and financial powers delegated Yes 3. % of sampled state and district program managers 91.30% aware of their responsibilities 4. % of sampled state and district programme managers They havent completed six whose performance was reviewed during the past six months, however a mid term months evaluation has been scheduled at state capital on 6th and 7th Oct. 06 5. % of district not having at least one month stock of a. Measles vaccine b. OCP 0% for Measles vaccine c. Gloves in the past six months? Data for OCP and gloves NA 6. % of districts reporting quarterly financial performance 57.89% in time 7. % of district plans with specific activities to reach District planning interventions vulnerable communities mobile medical van for RI, mobile medical unit, APHC outsourcing, free registration for BPL, free drug scheme reduced rates of Pathology and radiology 8. % of sampled outreach sessions where guidelines for 60% PHCs have pits for disposal AD syringe use and safe disposal followed .1ml-89% .5ml-92% (routine monitoring by partners and SHSB Aug. 06) 9. % of sampled FRUs following agreed IP and health Training scheduled in October 06 care waste disposal procedures CBMW facility in Patna Incinerators in other bigger districts on the anvil 10. % of 24 hrs PHCs conducting minimum of 10 28% deliveries per month 11. % of CHCs upgraded as FRUs offering 24 hrs EmOC 47% of facilities identified for FRUs services currently conducting CS 12. % of sampled health facilities offering RTI/ STI Next JRM services as per the agreed protocols 13. % of sampled health facilities offering RTI/ STI services as per the agreed protocols

- 80 -

BIHAR JRM Visit Report 1. Annual progress on financial & key RCH results indicators: Data on this was not available during the field visit.

2. Significant developments & progress overview since last JRM: Reforms in the State since the last JRM. The team is pleased to note that several key reforms have been completed by the state. Details of the reforms and other achievements are provided below. Integrated State level Health Society created. All technical unite are represented in the Society. 38 District Health Societies formed and 21 District Project Management Unit are fully staffed Rationalization of available human resources done to make 398 Block PHCs functional round the clock ; Delegation of powers to district level to transfer medical officers to achieve rationalization; Contractual staff (MOs) being recruited at Districts Outsourcing to the private (NGO) sector of Additional PHCs for OPD services (36 already outsourced); laboratories (2 agencies covering 19 districts each) and radiology services ; Mobile Medical Units with performance based contracts have been introduced ( 4 currently operational). Limited number of drugs (13 for OPD and 24 for IPD in case of PHCs), have been supplied to PHCs and are being provided free of cost at all PHCs and District Hospitals; Civil Surgeons have been delegated powers to order drugs at rate contracts. An officer authorized by the District Magistrate will be identified to inspect the supplies at the CSs store and the facilities; Public disclosure through clear signage of drugs in stock and staffing shifts at health facilities; Central rate contracts for hospital maintenance (diet, cleaning, laundry etc.). Each district has option to pick one of the three providers identified; Establishment of a data centre at the State Society to monitor performance of PHCs/Sub-District and District Hospitals on a 24 hour basis.

Major Achievements to date: Over four-fold increase in Full Immunization from 11% in 2001 to 43% Several fold increase in use of Primary Health Centre OPD services from 39 patients to over 2000 per month Improved management of outbreaks of Kala Azar cases. The PHCs visited were offering full treatment and diet. The treatment cards are being maintained very well and service providers were working hard under difficult conditions. The cold chain has been decentralized to the PHCs

General Observations: Prevention of outbreaks, such as that of the current outbreak of Kala Azar requires priority attention in addition to treating cases. Immediate measures such as identification of high risk groups by mapping the locations from where cases are reporting to PHCs and ensuring quality spray operations should be a priority for the state. Adequate financial provision also needs to be made for the spraying. Increasing patient attendance at PHCs may impact the work load of the staff and there is need to sustain the morale. Motivational training and performance appraisal systems for

- 81 -

rewards for increased coverage and better performance may now need to be considered. District hospitals at Hazipur and Gaya were not offering quality comprehensive emergency obstetric care services; the major limiting factors include non availability of anesthesiologist, proper OT and basic equipment. The sub centre kits are not available as well. Basic equipment such as BP and weighing machines are in very short supply at all levels of facilities. Quality of care, infection management and disposal of the health care wastes including auto disabled syringes, sharps and human parts need priority attention. PHC in charge medical officers are not familiar with most recent NRHM/RCH/State guidelines and policies for service delivery. There is need for disseminating this information to them on a regular basis. Any changes/revisions to the existing guidelines or norms need to also communicated to all.

Key implementation issues & recommendations: Key Implementation Issues from August 2006 JRM 1. Program Management Issues Leadership in SPMU changed thrice over the past year. Relationship between DHS; DPMU and the CS needs clarity; high levels of attrition at the DPMUs. Contract for NGOs to manage APHCs does not adequately detail roles and responsibilities of both parties; NGOs not being paid on time; appropriate M&E mechanisms not in place to assess their performance . Observations / Recommendations based on last JRM Continuity of leadership at SPMU critical SPMU to clarify roles and responsibilities and reporting structures to all concerned preferably through an orientation/training program ; Staffing of remaining 17 DPMUs need to be completed urgently; NGO contract need to specify clear roles and responsibilities of all parties; provide clarity on deliverables, including prioritization of VGs and hard to reach areas; and, monitoring and evaluation mechanisms Reallocation of APHC staff to Block PHCs in order to make the BPHCs functioning 24X7; DMs given authority to transfer doctors; Specialists from the private sector have been contracted in to provide services; Contractual ANMs (400) per session recruited at districts; Mapping of facility requirement based on population norms; RKS functional with involvement of PRI members at all facility levels One-third of funds allocated for 2005-06 were utilized; Lack of financial management staff at district level (17 positions vacant) leading to delays in submission of FMRs. 75% of current year PIP budget available with state; Rs. 24 Crores from RCH I need to be settled. Block level PMU recruitment process needs top be initiated soon Funds utilization for NRHM poor due to lack (late) of dissemination of guidelines for untied funds, RKS, JSY. Audit reports for 2005-06 due on July 31, 2006. Finalized procurement plan; developed procurement
- 82 -

2. Financial Management Most funds unutilised except for immunisation component review of financial management & delegation is required urgently

3. Procurement Management

Key Implementation Issues from August 2006 JRM

Observations / Recommendations based on last JRM guidelines Adopted state government procurement procedures for services and goods List of essential drugs for OPD and IPD use developed by expert committee Rate contract finalized Process of procurement of RCH drug kits and ASHA kits needs to be expedited; funds for these kits has been released by MOHFW for 2006-07 in March 2006

4. Technical Interventions (a) Maternal Health Outreach services provision Manpower plan for FRU operationalization required Up gradation of health facilities to be carried out on priority

TT immunisation being provided, but no other ANC service is being provided since ANM does not have equipment or training for this. Institutional deliveries represent a missed opportunity for essential neonatal and postnatal care, initiation of breast feeding and promotion of family planning. Facilities poorly equipped, lacking water and basic amenities especially for conducting deliveries. Life saving drugs i.e. magnesium sulphate and oxytocis should be included in the essential drug list Lack of trained and practicing anaesthetists constraints provision of C-section. MTP is provided only along with female sterilization. There is an understanding among service providers that Blood banks operational in districts 76 FRUs identified; UNICEF to complete up gradation plan by December 2006 All inputs such as, equipment supply and maintenance, drugs, staffing and training for PHCs, FRUs and District Hospitals, need to be synchronized with physical up gradation Immunisation progressing well; attempts now need to focus on the hard to reach. Essential new born care not being provided at all levels; state should look at joint training of ICDS workers and ANMs. Space identified for Sick New Born Care at DH Vaishali and NNF experts have completed needs assessment. Rapid scale up of IMNCI by involving more training institutes and more district. Spacing methods not evident in public facilities. Female sterilisation provided on a seasonal basis; circular issued for weekly service provision from Sept 2006.

(b) Child Health Good progress in immunisation (hard to reach areas, alternate vaccine delivery) Sick new born care centre planned at DH Vaishali IMNCI state level TOT completed ( c) Population Stabilization Work on community mobilization, BCC and training (d) Adolescent Health/ Urban health

- 83 -

Key Implementation Issues from August 2006 JRM TA in ARSH, should be part of RCH 5.Innovations More innovative partnerships required till public sector starts functioning

Observations / Recommendations based on last JRM No action taken on ARSH

6.Equity and Access focus on vulnerable groups is required

Outsourcing of 36 Additional PHCs to NGOs; and laboratory (2 agencies covering 19 districts each) and radiology services to private sector Introduction of Performance based contracts for APHCs, Mobile Medical Units Establishment of a data centre to monitor performance of PHCs. Public disclosure through clear signage of drugs in stock and staffing shifts at health facilities Rationalization of available human resources to make 398 Block PHCs functional round the clock. Central rate contracts for hospital maintenance (diet, upkeep etc.) Each district will have option to pick one of the three providers identified; Alternate vaccine delivery system Identification of under-served areas and populations not being done in the planning for services. Preparing District Action Plans that take in to consideration the needs of groups that are not being reached. Pro poor performance indicators need to be developed for out sourced services, such as mobile clinics Availability of expensive services such as ambulance, x ray etc. for BPL patients needs to be ensured; Limited number of the recruited ASHAs belong to SCs and minority groups due to non availability of women in these groups, with the required level of schooling; therefore educational criteria for ASHAs from hard to reach groups and communities needed to be relaxed

7. M&E and TA Requirement Establishment of data centre at the state level and extension of the same to the district is underway

Service statistics are not being disaggregated; MIS formats from MOHFW to be used as basis of reporting; Capabilities need to be strengthened at both ends of the data centre pipe; analytical capacity has to be developed at the SPMU to inform decision makers at one end on decisions which need to be taken to strengthen program. Appropriate reporting formats need to be used at the districts; Systematic mechanisms to independently monitor outsourced operations needs to be introduced and institutionalized; M&E mechanisms should also bring in institutions who represent VGs and excluded groups; Robust systems and processes to monitor quality and

- 84 -

Key Implementation Issues from August 2006 JRM

Observations / Recommendations based on last JRM timeliness of proposed large scale Civil Works program need to be established.

8. Training / IEC and NGO involvement Comprehensive training Progress in designing specific training plans prepared plan/calendar required for SBA, anaesthesia, and IMNCI Orientation for Master trainers for SBA completed in 10 districts and 24 MOs, 464 AWW and ANMs trained so far in IMNCI Induction training of PMU officials and district program officers of 21 districts completed 9.Other issues 44374 out of 74316 ASHAs selected ; selection by PRI institutions 7 day Training provided to 14225. Compensation during training was made in time. ASHAs that worked with NGOs/self help groups in the past are more articulate and assertive

Priority actions to be taken: (Key areas that require urgent action to be completed after national level presentation and discussions)

- 85 -

BIHAR PROGRESS SINCE FIRST JRM State name: BIHAR Findings of 2 Joint Review Mission-RCH II, August/September 2006 Recommendations Progress overview and significant developments since February from February 2006 2006 JRM JRM 1. Program Management Issues Convergence of All national programs represented in SHSB and are actively all programs participating in decision making; Two core positions including required; manager finance vacant; Convergence with Increased support by MOHFW: Nodal officer for state, various ICDS for national program division officers are providing on-site support sustainability LDP; and guidance; More handholding 21 DPMUs fully operational; relationship required from GoI Reallocation of APHC staff to Block PHCs in order to make side; the BPHCs functioning 24X7; DMs given authority to transfer Address problem doctors; Specialists from the private sector have been contracted of manpower and in to provide services; Contractual ANMs (400) per session infrastructure recruited at districts; shortage; Mapping of facility requirement based on population norms; Unwilling to take RKS functional with involvement of PRI members at all facility decision on levels expenditure. 2. Financial Management One-third of funds allocated for 2005-06 were utilized; Q1 of Most funds 2006-07 utilization.. unutilised except for immunisation Lack of financial management staff at district level (17 component review positions vacant) leading to delays in submission of FMRs. of financial 75% of current year PIP budget available with state; Rs. 24 management & Crores from RCH I need to be settled. delegation is required Block level PMU recruitment process needs top be initiated urgently soon Funds utilization poor due to lack of dissemination of guidelines for untied funds, RKS, JSY. Audit reports for 2005-06 due on July 31, 2006. 3. Procurement Management Finalized procurement plan; developed procurement guidelines Adopted state government procurement procedures for services and goods List of essential drugs for OPD and IPD use developed by expert committee Rate contract finalized Process of procurement of RCH drug kits and ASHA kits needs to be expedited; funds for these kits has been released by MOHFW for 2006-07 in March 2006 4. Technical Interventions (a) Maternal Health Manpower plan TT immunisation being provided, but no other ANC service is for FRU being provided since ANM does not have equipment or training operationalization for this.
nd

- 86 -

State name: BIHAR Findings of 2nd Joint Review Mission-RCH II, August/September 2006 Recommendations from February 2006 JRM required Upgradation of health facilities to be carried out on priority Progress overview and significant developments since February 2006 JRM Institutional deliveries represent a missed opportunity for essential neonatal and postnatal care, initiation of breast feeding and promotion of family planning. Facilities poorly equipped, lacking water and basic amenities especially for conducting deliveries. Life saving drugs i.e. magnesium sulphate and methergine should be included in the essential drug list Lack of trained and practicing anaesthetists constraints provision of C-section. MTP is provided only along with female sterilization. Blood banks operational in districts 76 FRUs identified; UNICEF to complete up gradation plan (BoQ) by December 2006 All inputs such as, equipment supply and maintenance, drugs, staffing and training for PHCs, FRUs and District Hospitals, need to be synchronized with physical up gradation Immunisation progressing well; attempts now need to focus on the hard to reach. Essential new born care not being provided at all levels; state should look at joint training of ICDS workers and ANMs. Space identified for Sick New Born Care at DH Vaishali and NNF experts have completed needs assessment. Rapid scale up of IMNCI by involving more training institutes in Vaishali

(b) Child Health Good progress in immunisation ( hard to reach areas, alternate vaccine delivery) Sick new born care centre planned at DH Vaishali IMNCI state level TOT completed ( c) Population Stabilization Work on community mobilization, BCC and training

Spacing methods not evident in public facilities. Female sterilisation provided on a seasonal basis; circular issued for weekly service provision from Sept 2006.

(d) Adolescent Health/ Urban health TA in ARSH, No action taken on ARSH should be part of RCH 5.Innovations More innovative Outsourcing of 36 Additional PHCs to NGOs; and laboratory partnerships required (2 agencies covering 19 districts each) and radiology services to till public sector starts private sector functioning Introduction of Performance based contracts for APHCs, Mobile Medical Units Establishment of a data centre to monitor performance of PHCs. Public disclosure through clear signage of drugs in stock and staffing shifts at health facilities

- 87 -

State name: BIHAR Findings of 2nd Joint Review Mission-RCH II, August/September 2006 Recommendations from February 2006 JRM Progress overview and significant developments since February 2006 JRM Rationalization of available human resources to make 398 Block PHCs functional round the clock. Central rate contracts for hospital maintenance (diet, upkeep etc.) Each district will have option to pick one of the three providers identified; Alternate vaccine delivery system 6.Equity and Access focus on No action taken on planning specifically for VGs and hard to vulnerable groups is reach areas required 7. M&E and TA Requirement Focus needed on Establishment of data centre at the state level and extension monitoring of ASHAs of the same to the district is underway and RKS is 8. Training / IEC and NGO involvement Comprehensive Training plan prepared for SBA, anaesthesia , and IMNC training plan/calendar Orientation for Master trainers for SBA completed in 10 required districts and 24 MOs, 464 AWW and few ANMs trained so far in IMNCI Induction training of PMU officials and district program officers of 21 districts completed 9.Other issues 44374 out of 74316 ASHAs selected ; selection by PRI institutions 7 day Training provided to 14225. Compensation during training was made in time. Limited number belonging to SCs and Minority groups due to non availability of women with required schooling; relaxation in educational criteria needed to have ASHAs from hard to reach groups and communities ASHAs that worked with NGOs/self help groups in the past are more articulate and assertive

Facility Observation Checklist - District Gaya (Bihar) Pilgrim Belaganj Jammuawa APHC Wazirganj District PHC Sub Centre Tarawa PHC Hospital (5/9/06) (5/9/06) (5/9/06) (5/9/06) (5/9/06) N N Only in camp N N NA N NA N NA N N Y N Periodic N N N N N District Hospital Female (5/9/06) Y Y Reg N

Parameters Service Provision - Routine Delivery Services (24hrs) - Manage Obs. Complications - Female Sterlisation Services - NSV Services

- 88 -

Facility Observation Checklist - District Gaya (Bihar) Pilgrim Belaganj Jammuawa APHC Wazirganj District PHC Sub Centre Tarawa PHC Hospital (5/9/06) (5/9/06) (5/9/06) (5/9/06) (5/9/06) N NA N N N N N Y Y N N N N Y Y Y Y N N N Y Y N N N Y NA NA Y NA N N N N N N Y N N N N N NA N N N N N N N N N N N N Y Y Y N N N Y N Y N N Y Y N N Y N N N N N Y Y Y Y N N N Y Y N N Y Y Y Y Y Y N N N N Y Y Y Y N N Y Y N N N N District Hospital Female (5/9/06) Y Y N Y Y N N Y Y Y Y N N Y Y N N Y N

Parameters - MTP Staff Availability - Ob/Gyn or trained M.O - Anaesthesiologist - Staff Nurses/ANM's (atleast 4) - Lab Technicians Equipment and Supplies - NSV Kit - Gluteraldehyde Solution - RPR Test Kits - Injection Magnesium Sulphate - Doxycycline - Functioning BP Instrument - Measles Vaccine Facility Infrastructure - Needs assessment done - Plans for Bio-waste disposal - Visual Privacy in Labor Room - Visual Privacy in OPD - Back-up power facility Referral Services - Ambulance availabilty Client Convenience - Covered waiting area - Toilets (separate,clean and functional) - Signage to guide client - Signage on rooms Record Review Average number of monthly instituional deliveries in the last quarter

NA

NA

200

Facility Observation Checklist - District Vaishali (Bihar) Hajipur District Narainpur Hospital Mahua SubBijupur Parameters (5/9/06) PHC(5/9/06) centre(5/9/06) PHC(5/9/06) Service Provision - Routine Delivery Services (24hrs) Y Y N Y - Manage Obs. Complications N N N N - Female Sterlisation Services R R NA R - NSV Services R N NA N - MTP N N NA N Staff Availability - Ob/Gyn or trained M.O Y N N Y - Anaesthesiologist N N N N - Staff Nurses/ANM's (atleast 4) Y Y Y Y

- 89 -

Facility Observation Checklist - District Vaishali (Bihar) Hajipur District Narainpur Hospital Mahua SubBijupur Parameters (5/9/06) PHC(5/9/06) centre(5/9/06) PHC(5/9/06) - Lab Technicians Y N N N Equipment and Supplies - NSV Kit N N N N - Gluteraldehyde Solution N N N N - RPR Test Kits N N N N - Injection Magnesium Sulphate N N N N - Doxycycline Y Y N Y - Functioning BP Instrument Y Y N Y - Measles Vaccine Y Y N Y Facility Infrastructure - Needs assessment done Y N NA Y - Plans for Bio-waste disposal N N N N - Visual Privacy in Labor Room N N NA N - Visual Privacy in OPD N N NA N - Back-up power facility Y Y NA Y Referral Services - Ambulance availabilty Y Y NA Y Client Convenience - Covered waiting area N N NA - Toilets (separate,clean and functional) Y N NA N - Signage to guide client N N NA N - Signage on rooms N N NA N Record Review Average number of monthly instituional deliveries in the last quarter 4 NA 10

- 90 -

RCH II: FINDINGS OF 2ND JRM CHHATTISGARH Chhattisgarh has made steady progress. Grass root level link workers (Mitanins) have been institutionalised and provided with support in the form of drug kits, training, etc. In order to further improve delivery of services, the state should give greater focus on areas of: governance including filling up vacant positions for technical and non technical staff; financial management systems including timely reporting on UCs, dissemination of guidelines for untied funds to all levels; technical interventions including wider dissemination of JSY guidelines, greater focus on IMNCI trainings; convergence with various NRHM departments and among health programmes. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs.32.50 Crores Rs. 27.46 Crores Rs. 9.19 Crores 33%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS 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. FINANCIAL MANAGEMENT States fund allocation has increased GoI to ensure timely release of by almost 50% compared to pervious year advance funds for mandatory activities (JSY, compensation for sterilisation etc). State should reflect the amount received, released and actual expenditure incurred. Provide at least provisional UCs on the 1st year funds, in order to access the 2nd year funds. Develop mechanism for sanctioning funds by CMO up to a ceiling in the absence of the DM to avoid delays. Disseminate guidelines on utilisation of untied funds to various levels SUGGESTED ACTIONS

- 91 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

TECHNICAL INTERVENTIONS 874 SHCs made functional Drug kits, educational material distributed to all Mitanins BEmOC started in 20 FRUs (63%) and CemOC in 9 FRUs (28%) Increase in normal deliveries in 80% Widely Disseminate clear FRUs information on JSY at all levels using innovative strategies. 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 and conduct IMNCI training based on the national framework guidelines. Carry out biannual Vitamin A supplementation with deworming in all the children. To explore PPP mechanism to recruit contractual staff and make the urban health centres more functional. To implement the adolescent health programme as budgeted in the PIP. Conduct training of counsellors and peer educators at block level 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 TRAINING/ IEC/ NGO INVOLVEMENT Training load reduced for training Combine different trainings programmes (IMNCI, SBA, etc.) to Integrate courses for enhance its effectiveness in smaller paediatrics, management institutions. RTIs/STIs, IMNCI, MTPs in the training courses for multiskilling. Development partners to help in upscaling IMNCI and SBA, EmOC, Anaesthesia training.

- 92 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS Finalise the setting up of SIHFW and carry out training audit at regular intervals. Conduct orientation programmes to medical and nonmedical 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.

INNOVATIONS Jeevan Deep Samitis (modified RKS) Disseminate consistent and for encouraging greater citizens clear guidelines about Jeevan Deep participation in running health facilities 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. 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 eg admission, discharge, delivery and death

- 93 -

ACHIEVEMENTS/ OBSERVATIONS OTHERS

SUGGESTED ACTIONS 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

- 94 -

Progress on 13 identified process indicators (as provided by the state)

Sr. No. 1 2 RCH INDICATOR % of ANM positions filled a. % of districts having full-time programme managers for RCH b. Administrative and financial powers delegated 3 % of sampled state and district program managers aware of their responsibilities % of sampled state and district programme managers whose performance was reviewed during the past six months % of district not having at least one month stock of d. Measles Vaccine e. OCP f. Gloves in the past six months? % of districts reporting quarterly financial performance in time % of district plans with specific activities to reach vulnerable communities % of sampled outreach sessions where guidelines for AD syringe use and safe disposal followed % of sampled FRUs following agreed IP and health care waste disposal procedures % of 24 hrs PHCs conducting minimum of 10 deliveries per month % of CHCs upgraded as FRUs offering 24 hr EmOC services % of sampled health facilities offering RTI/STI services as per the agreed protocols M&E Triangulation Level of achievement 78% 75% MOV/OVIs
6199 out of total 6896 sanctioned posts for Lady health volunteer filled 13 out of 17 sanctioned posts filled

No State and District PMUs established Roles and responsibilities of SPMUS/ DPMUs yet to be clearly defined and streamlined and hence remain underutilised No annual workplan or performance appraisal system defined for PMU

100%

0 0 0

6 7

56%

10 out of 17 Accounts Manager appointed. 16 District Health Societies established

Specific plans developed for reaching tribal populations for specific districts through funds available under the Special Tribal Authority.
It is sampled during RI, catch up rounds

19%
None of the facilities visited were following systematic guidelines for managing Health Care Waste Management. 74 PHCs are functional as 24 hour sites for institutional delivery 11 out of 32 FRUS operationalised

10 11 12 13

77% 25%

- 95 -

RCH II: FINDINGS OF 2ND JRM CHANDIGARH Chandigarh has health indicators which are better than those targeted by GOI for 2010. However, the state should not be complacent . There is a need to expedite all planned activities for achieving better health care services especially to the vulnerable population in the city. !00% immunisation should be targeted. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 1.00 Crores Rs. 0.74 Crores Rs. 0.64 Crores 86 %

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE Planning cell for RCH II constituted TECHNICAL INTERVENTIONS Upgradation of 2 CHCs in progress Availability of gynaecologists and paediatricians on call 24 hrs Functional OT in 2 CHCs Outreach sessions 2-3 per week conducted in slums and peri urban areas. Coordinated activities conducted with Department of Social Welfare, Deptt.of Education, Deptt.Of Technical Education and Municipal Corporation at the city level .

Prosecute doctors under PNDT Achieve 100% immunisation

TRAINING/ IEC/ NGO INVOLVEMENT Health Mela, Posters, Video Films and preparation of tableau for IEC/ BCC M&E AND TA REQUIREMENTS Work has been initiated by Deptt. of Community Medicine, PGIMER, Chandigarh on baseline survey

- 96 -

RCH II: FINDINGS OF 2ND JRM DAMAN & DIU Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 0.50 Crores Rs. 0.23 Crores Rs. 0.43 Crores 187%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE It is decided by the UT Administration of Daman & Diu that the General Body of State Health Society will also function as State Health Mission since UT of Daman & Diu is small District Health Society and District Health Mission registered. FINANCIAL MANAGEMENT Rs. 35 lakh received out of which Rs. 23 lakh spent upto September30, 2006. INFRASTRUCTURE DEVELOPMENT As suggested in last JRM, one more CHC may be taken up under NRHM for upgradation to FRU. TECHNICAL INTERVENTIONS JSY notified and members of local body UT Admin. has requested MOHFW sensitised. to relax the criteria for the inclusion of ST beneficiary in addition to BPL since there are only 112 BPL family in U.T. of Daman & Diu The facilities of specialist i.e. Ob & Gy., Pediatrician, Anesthetic has already been provided in CHC Daman on visiting basis. Two gender sensitization and PNDT workshops have have been planned. Routine Immunization services strengthened by involving linked worker in industrial area. TRAINING/ IEC/ NGO INVOLVEMENT Discussion on with SIHFW in Ahmedabad for MO training in NSV. Awareness of RCH by Garba On Wheel during recent Navratri. Prototype IEC material developed. M&E AND TA REQUIREMENTS Data should be provided on the 13 process indicators: refer Annex II of the JRM Process Manual.

- 97 -

RCH II: FINDINGS OF 2ND JRM DELHI Government of Delhi is finally getting its act together and there is some movement in the right direction. However, institutional deliveries at 71% is a shame, since the corresponding figure for other metros is close to 100%. Delhi has been particularly slow in implementing RCH: JSY is yet to be launched, Programme Management Unit staff are not yet in place and the MNGO proposal has been pending with the government for more than a year. Key factors contributing to delay include multiplicity of agencies, large numbers of floating population, and lack of district set up in the health department. There is a need to evolve an effective institutional/ coordinating mechanism (possibly through NRHM) to ensure more rapid implementation. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 16.50 Crores Rs. 7.27 Crores Rs. 1.65 Crores 23 %

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE SPMU/DPMU staff not yet SPMU/DPMU staff needs to be recruited. HSCC contracted to recruit appointed on priority. State should closely contract programme management follow up with HSCC to ensure that staff. Recruitment advertisements to recruitment takes place on time. appear shortly. TECHNICAL INTERVENTIONS State and district level PNDT All cases of PNDT very old and no one meetings held on regular basis. PIL attending to these cases. State to follow up being filed. and ensure prosecution to convey the right message to all concerned. Plan for obstetric care through PPP being developed and this is a positive step (Pre RCH II survey of state govt. shows it is cheaper to use pvt facilities for basic obstetric care). However, even after 18 months of national launch, JSY is yet to be initiated. State to act quickly on implementing JSY. Focus on slum areas/ families opting for home deliveries through appropriate BCC Mother Dairy booths can be used for IEC (and also for social marketing of contraceptives Delhi govt. scheme for JSY could be used as pilot

Specifications for procurement of laparoscopes not in place. Tendering being done for AMC of existing laproscopes

Specifications for laparoscopes to be prepared by GOI and sent to state(s) (????). Training for laparoscopes to be synchronised with procurement

- 98 -

ACHIEVEMENTS/ OBSERVATIONS Slum areas need greater focus.

SUGGESTED ACTIONS Monthly health day to be convened regularly and quality ensured through trained and well equipped staff. Develop district plans and link up all slum areas for special focus so that they get required services/ benefits of RCH II

2 Dais trained

TRAINING/ IEC/ NGO INVOLVEMENT State should move away from Dai training and focus on training SBAs State should ensure adequate training load to make training cost effective. Needs to be expedited. A change in CDMO has, in the past led to alteration in classification of underserved areas for NGO schemes. This is not acceptable. Criteria for such classification to be reviewed

6 MNGOs selected to cover 8 districts of Delhi. They have selected field NGOs. Project proposals from NGOs still to be appraised

INNOVATIONS Emergency referral transport being Need for monitoring of emergency arranged through Centralised referral transport services. Adequate Accidents and Trauma Services. awareness generation for required (eg through newspapers, Mother Dairy booths, etc). M&E AND TA REQUIREMENTS State to provide documentary evidence for achievement of core 13 indicators as specified in Enclosure 4 of the JRM Process Manual (see below).

- 99 -

Progress on 13 identified process indicators (as provided by the state) S. RCH Indicator Level of Remarks No. Achievement 1 % of ANM positions filled 19% 119 ANMs on contract in place. 630 new to be recruited 2 a. % of districts having full time Nil CDMOs/ ADMOs carry ou the programme manager for RCH work. b. Administrative and financial powers delegated Nil 3 % of sampled state and district NA All the CDMOs/ Addl CDMOs programme managers aware of are aware of their responsibilities their responsibilities 4 % of sampled state and district 100% All the Districts are sending programme managers whose regular report about vaccination, performance was reviewed family planning, PNDT and other during the past six months aspects of RCH 5 % of districts not having one month stock of a. Measles vaccine Nil b. OCP Nil c. Gloves Nil 6 % of districts reporting quarterly NA District health societies are financial performance in time going to be in place very soon. 7 % of district plans with specific 100% Medical care is being provided to activities to reach vulnerable JJ clusters and slums through communities mobile dispensaries RCH services are being provided through NGOs and GIA is given to these NGOs. 8 % of sampled outreach sessions 100% where guidelines for AD syringe use and safe disposal followed 9 % of sampled FRUs following 100% All the 100 bedded hospitals agreed IP and health care waste acting as FRUs are strictly disposal procedures following guidelines of Proper health care waste disposal 10 % of 24 hrs PHCs conducting 14.28% Only one PHC at Najafgarh is minimum of 10 deliveries per conducting out of seven PHC in month Delhi 11 % of CHCs upgraded as FRUs Nil CHC are not there in Delhi offering 24 hr Em OC services 12 % of sampled health facilities 100% 11 RTI/STI clinic are there as offering RTI/ STI services as per per information from AIDS the agreed protocols control branch. However all the Lab Technicians have undergone training which are working in Delhi Govt hospitals 13 M & E Triangulation -Next JRM

- 100 -

RCH II: FINDINGS OF 2ND JRM GOA With MMR of 25, IMR of 12 and 88% institutional deliveries, Goas main challenge is to sustain service levels and ensure that the needs of the unserved are catered to. It is regrettable that there has been no progress on problems identified in the first JRM, especially shortage of medical staff. 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. District plans should be prepared. Financial progress Allocation (05-07) Release (1/4/05 to 30/6/06) Expenditure (1/4/05 to 30/6/06) Expenditure/ Release

Rs. 3.00 crs Rs. 1.51crs Rs. 0.35 crs 23%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS

GOVERNANCE Contractual medical positions could not Advertise in neighboring states be filled. Posts have been re Specialists ( trained MBBS) to be posted to advertised. However, the response is the appropriate facility. not satisfactory. Revisit this; if capacity insufficient, desirable to set up SPMU/DPMU SPMU/DPMU not required FINANCIAL MANAGEMENT Confusion on central Govt.s stand on State needs to send the technical procurement of laparoscopes. specification required for the laparoscopes to the central Govt. so that further action could be taken. With the existing budget Kit A and Kit B Procurement of Kit A and Kit B to be carried couldnt be procured. on as per the PIP State may use the same rate contract as used by neighboring states to procure drugs. Confusion on central Govt.s stand on Inverters can be procured ,if approved in procurement of invertors for UPS the PIP. TECHNICAL INTERVENTIONS The number of potential beneficiaries is Consider the suggestion of previous JRM meager, hence, low expenditure on mentioning the need to identify pockets of JSY. underserved population groups. Consider administrative decentralization to panchayats Prepare district plans

- 101 -

ACHIEVEMENTS/ OBSERVATIONS Allocation for up gradation of State Family Welfare Bureau has not been spent due to unavailability of additional space.

SUGGESTED ACTIONS

INFRASTRUCTURE DEVELOPMENT

Upgrade the existing allocated space of State Family Welfare Bureau

TRAINING/ IEC/ NGO INVOLVEMENT Trainings could not be taken up as lack Develop a CTP and identify appropriate of training infrastructure agencies. M&E AND TA REQUIREMENTS State to provide documentary evidence for achievement of core 13 indicators as specified in Enclosure 4 of the JRM Process Manual (see below).

OTHERS .

Re-look into the district mission. Its useful to have it along with a strong PRI.

- 102 -

Progress on 13 identified process indicators (as provided by the state) S.No. RCH Indicator Level of Remarks Achievement 1 % of ANM positions filled 98% 2 a. % of districts having NA No district level decentralization in full time programme health administration in the state of manager for RCH Goa. b. Administrative and financial powers delegated 3 % of sampled state and NA No district level decentralization in district programme health administration in the state of managers aware of their Goa. responsibilities State level programme officers fully aware of the responsibilities 4 % of sampled state and district programme managers whose performance was reviewed during the past six months % of district not having one month stock of a. Measles vaccine b. OCP c. Gloves % of districts reporting quarterly financial performance in time NA No district level decentralization in health administration in the state of Goa. State level programme officers fully aware of the responsibilities

0%

NA

No district level decentralization in health administration in the state of Goa. No district level decentralization in health administration in the state of Goa.

% of district plans with NA specific activities to reach vulnerable communities % of sampled outreach sessions where guidelines for AD syringe use and safe disposal followed % of sampled FRUs following agreed IP and health care waste disposal procedures % of 24 hrs PHCs conducting minimum of 10 deliveries per month % of CHCs upgraded as FRUs offering 24 hr Em OC services 100%

System not yet established. However, both the district hospitals functioning as FRUs follow proper bio-medical waste disposal. 77% All the five CHCs are planned to be FRUs and accordingly infrastructure facilities provided. However, the posts

10 11

- 103 -

S.No.

RCH Indicator

Level of Achievement

Remarks of Obstetricians, Anesthesiologist are not getting filled.

12

13

% of sampled health facilities offering RTI/ STI services as per the agreed protocols M & E Triangulation

75%

Next JRM

- 104 -

RCH II: FINDINGS OF 2ND 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 scheme appears to be highly promising . Gujarat is the only state to have reported disaggregated data for SC/ST population on the indicators for performance bonus i.e measles coverage and institutional delivery. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 60.50 Crores Rs. 33.83 Crores Rs. 22.12 Crores 65%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS GOVERNANCE State and District level missions are in place. PRI representation in district missions. Merger of Dept.s of Health and Family Welfare, and of societies at State and district levels. SPMU and DPMUs fully in place. Programme Implementation Unit also set up (PIU). RKS set up in all districts and CHCs. FINANCIAL MANAGEMENT Less than 12% of the funds received for FY2006-07 have been utilised. Rs. 39.40 crores received from GoI during the reporting period for 197 CHCs upgradation to IPHS, civil work initiated by PIU TECHNICAL INTERVENTIONS ISM doctors trained and posted in PHCs, SCs and mobile units, to overcome persistent vacancies. Use this as stop gap only. Long term aim is one allopathic and one AYUSH doctor/PHC so that people have a choice. Step up fund utilisation. SUGGESTED ACTIONS

INFRASTRUCTURE DEVELOPMENT

Slums in 143 municipalities have been covered in 1 phase under Urban RCH. Now Tribal areas being taken up. Existing 85 Mobile Health Units are repositioned to cover remote areas and operationalised. MHUs have done mapping of
st

- 105 -

ACHIEVEMENTS/ OBSERVATIONS remote areas. Strengthening of Immunisation Micro Plans implemented District funds released Guidelines provided TOT of RCHO for ADS & Biomedical waste done Chiranjivi Scheme up scaled to entire State. (22263 beneficiaries). JSY merged with Chiranjivi Scheme. 600 gynaecologists working with Chiranjivi Scheme to increase to 1200. Chiranjivi doctors have agreed to perform sterilisations.

SUGGESTED ACTIONS

Monitoring and enforcement of PNDT is not adequate. One Sting operation for sex determination successfully completed in Sep, 2006. 136 USG sealed, legal actions have been taken against 74 institutions/ doctors for violation of the act, 13 Cases are pending in the High Court. 43 Talukas have very poor sex ratio (in 700s). Increase in ANC, institutional deliveries, and post natal care. Good progress of IMNCI training of MOs, SNs, and AWWs, in IMNCI districts. Emergency New Born Care training being done in the 16 non-IMNCI districts. Since no ASHAs, dais are being trained in child health. Immunisation coverage is slipping. IUD use has increased. Not much attention being given to NSV. CONVERGENCE Convergence with ICDS 1024 AWWs as ASHA/ CBHVs (97%) IMNCI training of 3443 AWWs (40%) Monthly Health & Nutrition day activity

To ensure that no coercion is used for sterilisation using Chiranjivi doctors. Put mechanism in place to ensure that service standards are maintained in Chiranjivi Scheme. Chiranjivi doctors can be involved in safe abortions, and RTI/STI. Ensure stricter monitoring of sex ratio and enforcement of PNDT Act. Ensuring quick prosecution enhances the impact of PNDT Act.

This should be tackled ona priority basis. Need to focus on NSV.

- 106 -

ACHIEVEMENTS/ OBSERVATIONS TRAINING FOGSI and 2 private medical colleges involved in training Strengthening of SIHFW Progress in trainings for SBA, BemOC, CemOC, Anaesthesia skills, RTI/STI. Resulted in 5 new FRUs being operationalised and 3-fold increase in deliveries in these institutions. Shortage of Anaesthetists has been overcome in 8 FRUs. INNOVATIONS / PPP HIV/AIDs incorporated into the integrated health societies. Use of ISM doctors in PHCs and below. Outsourcing of Biomedical Waste disposal Private gynaecologists linked with CHCs/FRUs on call basis. IUD insertion training incorporated in SBA training. EQUITY AND ACCESS 7 CHCs and 1 PHC are run by NGOs Vandemataram scheme for ANC NGO 18 MNGOs covering 22 districts. 57 field NGOs in 17 districts. 3 Service NGOs. Partnership with Dai Sangathan covering 11 districts.

SUGGESTED ACTIONS

M&E AND TA REQUIREMENTS HMIS training completed. Computer compatible HMIS in place. Mapping for monitoring immunisation has been develop. Plan to extend it for overall RCH monitoring.

- 107 -

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

Level of Achievement --------0%

6 7 8 9 10 11 12 13

----100% --77% 35% -----

- 108 -

RCH II: FINDINGS OF 2ND JRM HARYANA Overall Haryana s progress has been satisfactory. Several initiatives have been undertaken to improve access to health services and to address equity, such as Delivery Huts, JSY in urban slums for BPL families, partnerships with NGOs. Programme Management units need to be fully operational with staff recruited and trained to ensure better planning at district and sub-district levels. Additionally, some RCH I trainings are still being conducted. Need to conduct more training programmes utilising the newer modules, including SBAs, and multi-skilling of MOs. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 25.00 Crores Rs. 11.42 Crores Rs. 8.06 Crores 71%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS GOVERNANCE Hired Consultants in Planning, Health Economics, Community Mobilization & Chartered Accountant Hired 15 District Health Managers, 84 Accounts Assistants, 17 Secretarial Assistants and 85 Information Assistants Expenditure of Rs. 14.54 crores i.e. 43.9% of Base Flexible funds received Expenditure of Rs. 1.05 crore out of Rs.2.89 crore (36.4%) of untied funds for sub centres Expenditure of Rs.67.89 lacs (38.9%) out of Rs. 1.74 crore in Strengthening of Routine Immunization Expenditure of Rs. 45.04 lacs out of Rs. 2.27crore (19.84%) of Janani Suraksha Yojna INFRASTRUCTURE DEVELOPMENT 37 CHCs functioning as FRUs against target of 30. TECHNICAL INTERVENTIONS 327 Delivery Huts established to provide 24 hr safe delivery environment, services and referral support Launched IMNCI training in 5 selected districts Institutional deliveries increased to 43.6% EC to do evaluation of Delivery Huts. Speed up DPMU staff recruitment and subsequent training. Look at the Block level PMUs being done in Punjab. SUGGESTED ACTIONS

FINANCIAL MANAGEMENT

- 109 -

ACHIEVEMENTS/ OBSERVATIONS 3910 ASHAs signed agreements with Village Health & Sanitation Committees Training of ASHA completed in August 06 with expenditure of Rs. 22.87 lacs Rs. 7.83 lacs disbursed to ASHAs based on performance. CONVERGENCE Convergence Committee/Working Groups set up at State, district and block levels for convergence with Panchayati Raj, DWCD, and Rural Development. Participation of PRIs and other stakeholders in district/village health planning. TRAINING Mainstreaming of Gender Issues under RCH 120 SMOs (Haryana), 49 SMOs (J&K) Model Injection centre training PGIMER Faculty SIHFW (13 batches) Administrative & Management training at HIPA- 37 MOs A Deputy Director trained in World Bank Procurement Procedures Integrated Skill Training -94 MOs Two Gynaecologists undergoing Minimal Invasive Laparoscopic Surgery Training at PGI, Chandigarh Specialized Skill Trainings MTP- 38 MOs Specialized Skill Training Mini lap- 24 MOs Specialized Skill Training-IUD- 77 ANMs Launched JSY for BPL families in urban slums to promote institutional deliveries in accredited PHPs through MNGOs Launched pilot VIKALP Scheme in 4 districts and now extended to all districts to provide RCH services through PHPs INNOVATIONS Delivery Huts. Telemedicine project to develop Village Development Resource Centre at CHC Gohana and Sonepat district hospital in collaboration with Ganga Ram Hospital

SUGGESTED ACTIONS

Do monitoring of SBA and Anaesthesia trainings.

NGO INVOLVEMENT / EQUITY AND ACCESS

M&E AND TA REQUIREMENTS Monthly review of Civil Surgeons physical & financial progress and prioritisation of district Reduced & simplified the MIES registers at
- 110 -

ACHIEVEMENTS/ OBSERVATIONS Sub centre level with state wide operationalisation MIS made computer compatible at District level with e-connectivity. Progress on 13 identified process indicators: S.No. RCH Indicator 1 2 3 4 5

SUGGESTED ACTIONS

6 7 8 9 10 11 12 13

% of ANM positions filled a. % of districts having full time programme manager for RCH b. Administrative and financial powers delegated % of sampled state and district programme managers aware of their responsibilities % of sampled state and district programme managers whose performance was reviewed during the past six months % of district not having one month stock of a. Measles vaccine b. OCP c. Gloves % of districts reporting quarterly financial performance in time % of district plans with specific activities to reach vulnerable communities % of sampled outreach sessions where guidelines for AD syringe use and safe disposal followed % of sampled FRUs following agreed IP and health care waste disposal procedures % of 24 hrs PHCs conducting minimum of 10 deliveries per month % of CHCs upgraded as FRUs offering 24 hr Em OC services % of sampled health facilities offering RTI/ STI services as per the agreed protocols M & E Triangulation

Level of Achievement 92.3% 75% 100% 100% 0%

85% 0% 99.6% --13.12% 100% 47.7% ---

- 111 -

RCH II: FINDINGS OF 2ND JRM HIMACHAL PRADESH Himachal Pradesh has demonstrated overall improvement in its performance since the last JRM. Recruitment of personnel for program management units has made headway and technical interventions have been initiated for the major program components of RCH II. However, it is important to accelerate the pace of implementation. The State needs to resolve the problem of shortage of skilled manpower through a multi pronged strategy. Fund utilization and reporting from districts needs to be prioritised/ closely monitored. There is an urgent need for specific plan to address the needs of the most vulnerable groups. Financial progress ( 05-06) Allocation Release Expenditure Expenditure/ Release Rs. 7.50 Crores Rs. 5.00 Crores Rs. 3.21 Crores 64%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE Convergence of Health and FW Explore possibility of locating staff societies completed from other states. SPMU and DPMU staff are partially in place FINANCIAL MANAGEMENT Ensure regular receipt of FMR from districts TECHNICAL INTERVENTIONS 58 RKS formed in district hospitals RKS needs to take up issues in hospital management Process on for up gradation of CHC s to FRU 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 Recruitment of ASHA to be completed on priority Link trained ASHA to health facilities Provide requisition to GOI for AD syringes and essential equipments Disseminate correct information on JSY norms to communities through awareness programmes and IEC

Delay in appointment of ASHA

Shortage of AD syringes in all the facilities Confusion prevails among beneficiaries on the norms of JSY

- 112 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

TRAINING/ IEC/ NGO INVOLVEMENT Delay in training of health personnel Training camps need to be started urgently before the onset of severe winter EQUITY AND ACCESS Data on VG not available. No Maintain disaggregated data for specific plan in place to address their vulnerable groups (migrant workers, SC, needs ST, women) in all districts Problem of accessing delivery services in remote areas like Lahaul and Spiti 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.

M&E AND TA REQUIREMENTS M & E cell formed in the State Disseminate information on new M& E system to districts and blocks Technical Assistance required for monitoring, supervision and software application

OTHER ISSUES Remote areas, difficult terrain, Multi pronged strategy required for communication problems and lack of addressing problem of manpower. Tie adequate manpower up with existing resources Plan for a nurses cadre in the State to resolve the problem of shortage of technical staff

- 113 -

RCH II: FINDINGS OF 2ND JRM JAMMU & KASHMIR The State has been a late starter. The program planning was delayed and consequently implementation and fund utilization is poor.. Most of the activities of the RCH II program are in the initial stages of implementation. The pace of intervention needs to be fast tracked, to compensate for delay in start up. Establishment of program implementation and management support at the State and district level is a priority. Optimal utilization of existing resources and innovative collaboration with other stakeholders are necessary. Increased focus is required on capacity building of personnel across all levels. Improved fund utilization will facilitate future fund release. Financial progress ( 05-06) Allocation Release Expenditure Expenditure/ Release Rs. 12Crores Rs. 6.05 Crores Rs. 1.71 Crores 28%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE State PIP is being revised and Ensure that SPMU and DPMU are redrafted; to be submitted to GOI by 30th in place at the earliest Oct Completion of DAP to be done by Selection of SPMU and DPMU staff Oct. in process Merger of Health, and Family Welfare departments has been completed and merger of all district and state level societies is underway. . Funds made available to all districts FINANCIAL MANAGEMENT Low fund utilization due to delay in Expedite fund utilization and fund program planning reporting TECHNICAL INTERVENTIONS So far 4200 ASHA have been hired, Prepare training calendar for of which 3500 are trained ASHA. Emphasize training of ASHA in home based care Plans for recruitment of 6500 ASHA by Oct High unmet needs for spacing. Sterilization training carried out, but response from people is poor Lack of technical staff like Anaesthesiologists and Obstetricians Enhance awareness on unmet needs and sterilization options through specific IEC and BCC Priority planning required for increasing overall pool of technical staff through e.g. multiskilling of doctors

- 114 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS Clear operational strategy is required to implement IMNCI with outcome oriented approach

TRAINING/ IEC/ NGO INVOLVEMENT Preparation of BCC strategy is in Involve NGOs in creating process awareness of RCH II activities Training module prepared on home based care for ASHA No initiatives so far on NGO partnerships EQUITY AND ACCESS Inadequate number of ASHAs for Training for dais/mid wives in remote, sparsely populated rural areas remote areas as a stopgap measure. Eventually, the focus is on deliveries by Dais/mid wives are alternatives in SBAs. remote areas M&E AND TA REQUIREMENTS MIS development is in process. Introduce new M& E formats at the district level. Continue data collection M& E cell proposed in every district as per earlier system till new M& E system is set up OTHER ISSUES The State has adequate health Activate health infrastructures infrastructure in place through adequate staffing Lack of trained health personnel in Develop a nursing cadre, upgrade rural areas nursing institutes

- 115 -

RCH II: FINDINGS OF 2ND JRM JHARKHAND Jharkhand has shown significant progress since the last JRM. Considerable emphasis on strengthening institutional structures : Jharkhand Health Society is fully functional, several SPMU/DPMU staff have been appointed and trained and steps taken for integration with directorate staff. Several innovative schemes are at various stages of design/ implementation : democratic selection of Sahiyas (link workers) with active participation of tribal councils, forming a state mission for health insurance in partnership with private sector, catch up rounds for immunisation, etc. The state, however also needs to focus on nutritional interventions for women and young children, training of technical and other staff and strengthening of HMIS . Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 42.00 Crores Rs. 40.60 Crores Rs. 18.21 Crores 45 %

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE Almost 50% of SPMU/ DPMU Fast track recruitment of staff for positions filled. To overcome this vacant positions and subsequent constraint, each DPMU given training . responsibility of a group of neighbouring districts. FINANCIAL MANAGEMENT Financial audit reports need to be submitted to GOI in time TECHNICAL INTERVENTIONS Catch up rounds for immunisation Improvised voucher based scheme for JSY, for encouraging institutional delivery and child immunisation Focus on nutritional interventions for women and children Build a nursing cadre in state TRAINING/ IEC/ NGO INVOLVEMENT All vehicles of DoHFW carrying IEC Sensitise departmental staff in BCC messages ANMs given IEC bicycles Explore the option of providing scooter loans for ANMs INNOVATIONS

- 116 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

Selection of link workers (Sahiyas) Selection of Sahiyas by tribal councils through active participation from tribal can be replicated in NE states village councils. Zero diahhroea death programme, for checking diahhroea deaths Promotion of herbal medicines used by tribals through Sahiyas. Sarv Swasthya Mission being formed for health insurance in partnership with private sector. Tickler bags for maintaining immunisation cards and tracking left out cases, for ANMs. Carry bag with IEC message for ANMs M&E AND TA REQUIREMENTS Piloted health MIS in Lohardaga district. Plan to replicate the same statewide Catch up rounds and routine immunization have a focused MIS which is supplemented with external coverage evaluations, also serving as tool for data triangulation

- 117 -

Progress on 13 identified process indicators: S. RCH Indicators Level of No. Achievement 1 2 % of ANM positions filled a. % of districts having fulltime programme manager for RCH . b. Administrative & financial powers delegated ~ 80% (79%) 100% (36% if contractual district managers are considered)

Remarks 4291 ANMs are in position against a sanction of 5444. GOJ has identified full-time RCH program managers from their existing health staff in all 22 districts. 8 full-time district PMU managers are in position, another 5 are going through orientation at the state level. The 9 vacancies of district PMU managers have been advertised and by mid October, the district managers are expected to be in place. As an interim arrangement, GOJ has issued an office order (JS/094) dated July 31, 2006 assigning one district program manager the responsibility for a cluster of districts. A Office Order has also been issued with regard to the delegation of financial powers to the ACMO for all national programs. The GOJs office order (JS/094) dated July 31, 2006 mentioned above outlines the responsibilities of the district teams. Capacity building training has been provided to all state and district program managers. In addition, the district managers were provided 6 months induction training at state-level prior to moving them to the field. Training calendar has been developed for on-going training of SPMU & DPMU staff. The review process has recently been formalized and based on that the following meetings have been initiated: - weekly RCH meetings at district level - monthly review meetings of DPM with CS and ACMOs at state headquarter Formats for annual review have also been developed. These will be conducted once staff completes their first year of performance. Logistics Management is a key issue that needs to be addressed. Stock-outages are common; the LMIS system is very weak; poor records are being kept at PHC level.

% of sampled state and district program managers aware of their responsibilities

100%

% of sampled state and district programme managers whose performance was reviewed during the past six months

100%

% of district not having at least one month stock of a. Measles Vaccine 91% OCP b. OCP 86% Gloves c. Gloves 18% Measles

- 118 -

S. No.

RCH Indicators In the past six months

Level of Achievement

Remarks

% of districts quarterly performance in time

(milestone: < 10%) reporting 100% financial

% of district plans with specific activities to reach vulnerable communities

% of sampled outreach 81% sessions where guidelines for AD Syringe use and safe disposal followed

State provided information that indicated that all districts had provided the FMR for quarter ending March 2006 by April 15th and quarter ending June by July 21st. For last two quarters these reports were in time. The key evidence of this was related with the bi-annual catch-up rounds for immunization, IFA & Vitamin A coverage where the focus was to reach vulnerable communities (BPL, tribal, with poor access). Independent assessments of biannual rounds also collected disaggregated data. GoJ provided data that AD syringes were used in 466 of the 577 (80.76%) sessions that were monitored. During field-visits we confirmed availability of AD Syringes. The health workers including ANMs were aware of the benefits and provided accurate responses to safe disposal of these syringes. GOJ in the process of establishing the waste disposal procedures at FRUs. NA

10 11

% of sampled FRUs NA following agreed IP and health care waste disposal procedures % of 24 hrs PHCs 30% conducting minimum of 10 deliveries per month % of CHCs upgraded as 0% FRUs offering 24 hr EMOC services

12 13

% of sampled health facilities NA offering RTI/STI services as per the agreed protocols M&E Triangulation

GOJ in the process of upgrading CHCs as FRU as per IPHS norms. Site selection has been completed; proposals are being developed; consultants have been empanelled; and training of anesthetist is on-going NA GoJ does not have comprehensive plans for data triangulation. However, GoJ has commissioned external validation of the catch-up rounds and reviews the data to inform program.

- 119 -

RCH II: FINDINGS OF 2ND JRM KARNATAKA Karnataka could perform much better although there has been significant improvement with institutional delivery currently being 63% (departmental data) and complete immunisation being 87% (UNICEF 2005). While several strategies have been formulated for the northern districts with relatively poor indicators, ground level impact is yet to be seen. There has been enormous delay in recruitment of contractual staff; as well as in submission of financial audit reports leading to delay in release of funds from GoI. Financial progress Allocation (05-07) Release (1/4/05 to 30/6/06) Expenditure (1/4/05 to 30/6/06) Expenditure/ Release Rs. 126.0 crs Rs. 28.8crs Rs. 15.3 crs 53%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE ISSUES Program Assistant (Accounts) at Selected MBAs should be posted to the state and district levels in place. northern districts. (27+1). 17 MBAs selected for districts, but not yet in place. Very few other contractual staff in place: [Staff Nurse (128/326) in PHCs, Staff Nurse (52/100) in FRUs, ANMs (59/500), Doctors in PHCs (74/100), Lab Technicians (42/283) in FRUs] Retention of Staff Nurses is difficult Remote area allowance to doctors 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 neighboring states.

FINANCIAL MANAGEMENT Funds not released regularly from Inspite of accounts staff at districts, center due to delay in auditing of audit reports are delayed. This needs to be accounts. investigated Review of financial mngmt & delegation is required. Expedite the process of finance auditing and send reports to centre so that it can release funds more smoothly.

- 120 -

ACHIEVEMENTS/OBSERVATIONS

SUGGESTED ACTIONS

TECHNICAL INTERVENTIONS Blood banks being set up in FRUs State could enter into PPP with The Red Cross for management of blood banks. 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 Payment to be made by cash. Monthly health days to be implemented with full range of quality services.

2661 night deliveries till 30.6.06 in 254 PHCs in 6 backward districts Poor progress in outsourcing of specialist services to deal with high risk pregnancies JSY implementation weak, one of the reasons being payment by cheque to ANMs.

TRAINING/ IEC/ NGO INVOLVEMENT 14 MNGOs selected covering 17 Immediately conclude the field appraisal districts. for the remaining 9 districts EQUITY AND ACCESS Incentive to TBAs and ANMs in 6 Explore whether management of facility backward districts level services could be handed over to NGOs. M&E AND TA REQUIREMENT Printing and supply of CNAA Need to make sure that it has reached forms and register supply of ANC the concerned person at the grass root cards have been issued to the districts level. State to systematically provide documentary evidence for achievement of core 13 indicators as specified in Enclosure 4 of the JRM Process Manual.

- 121 -

RCH II: FINDINGS OF 2ND JRM KERALA Kerala is unarguably one of the best performing states of India. The state has the highest literacy rate as well as very good health seeking behavior. 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. Financial progress (2005-06) Allocation Release Expenditure Expenditure/ Release

Rs. 38.0 crs Rs. 21.44 crs Rs. 4.82 crs 22%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE ISSUES Mission Directorate formed and Need to expedite the process and fill up SPMU/ DPMUs constituted. However the posts as soon as possible neither SPMU/ DPMUs are fully staffed. District Health & Family Welfare Societies established (5 out of 14 dist). Process of merger of societies initiated in other districts. G.O. issued for reconstitution and Make sure that all the HDS of public registration of hospital development health institutions are registered within the committees in all the health mentioned time line (October 30, 2006). institutions. FINANCIAL MANAGEMENT State would like to use RCH II funds RCH II funds cannot be diverted towards for mental health mental health. Untied funds should be utilized judiciously as per the health priority of the community for RCH services State may request Ministry to permit reallocation of funds from disease control programmes to mental health. TECHNICAL INTERVENTIONS Involvement of ASHA in tribal area Kerala can appoint ASHA in tribal areas has not been considered. and link workers in urban and non-tribal rural areas. State may submit a detailed action plan for ASHA & link workers to GoI Low utilisation of SC and PHCs as Need to regularize SC and PHCs, people believe in secondary and improve standards and quality of services tertiary level or private clinics provided.

- 122 -

ACHIEVEMENTS/OBSERVATIONS 24x7 PHCs not required in the state (due to low utilisation rate) A detailed proposal for upgrading 30 bedded one Ayush hospital in each district is being processed. Many CHCs dont have gynecologists and there is a shortage of specialists in the CHCs.

SUGGESTED ACTIONS PhDs must be strengthened for future requirements of public health system GoI will consider the proposal.

No health melas conducted due to doctors strike No contractual ANM position filled cause of unfelt need

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. Make sure that the targeted health melas are conducted by the end of the financial year Need to revisit the idea of not filling up ANM positions. ANM positions may be filled for future public health system Make sure that all the buildings are eco friendly.

Funds received for up gradation of 106 CHCs (out of 115) to IPHS level

TRAINING/ IEC/ NGO INVOLVEMENT MNGO scheme is being implemented MNGOs must be called for periodic reviews INNOVATIONS First state in India working Need to look into costs of e banking towards e banking facility EQUITY AND ACCESS Need to look into referral protocols and revisit the whole referral system. May take the help of PRI M&E AND TA REQUIREMENT Facility Survey for all 115 institutions completed and documented State to provide documentary evidence for achievement of core 13 indicators as specified in Enclosure 4 of the JRM Process Manual.

- 123 -

RCH II: FINDINGS OF 2ND JRM LAKSHADWEEP Lakshadweep is on the right track. All it needs to do now is change gears. The UT has very good health indicators with zero MMR and 6.73 IMR. Lakhshadweep needs to work towards completing all the activities in their work plan. In addition, specialised doctors should be recruited as soon as possible. Financial progress (2005-06) Allocation Release Expenditure Expenditure/ Release Rs. 0.50 crs Rs. 0.12 crs Rs. 0.14 crs 117%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE ISSUES State mission is in position Problem in recruiting specialized Develop innovative strategy including doctors working with local specialists. No regular programme Need to revisit the requirement of a management RCH officer programme management RCH officer TECHNICAL INTERVENTIONS Shortage of SBA Nurses may be trained as SBA Need for more lady doctors Need to advertise for more lady doctors with a good pay package. TRAINING/ IEC/ NGO INVOLVEMENT EQUITY AND ACCESS Train good SBA at SC level Boat ambulances may be put in place Lakshadweep may propose to include chopper transfer service under JSY

High referral cost

- 124 -

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

Remarks

- 125 -

RCH II: FINDINGS OF 2ND JRM MADHYA PRADESH Impressive performance by the state so far. Several innovative practices are at various stages of implementation, some examples being: mobile medical vans providing package of health care services in 11 tribal blocks, scheme for financial assistance for institutional delivery and compensation for maternal deaths, 50 identified blocks being developed as model blocks with all essential health care facilities. There is a need now to consolidate innovations, strengthen institutional arrangements and monitor/ report on outcomes. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release Rs. 93.50 Crores Rs. 66.20 Crores Rs. 25.30 Crores 38 %

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE Full time Mission Director for NRHM Recruitment process to be monitored in place. SPMU/DPMU staff largely closely / fast tracked. recruited and trained. However, there are still a number of vacancies. An advertisement has been recently released. Formulated guidelines for delegation Need for adequate delegation of of administrative and financial powers at administrative and financial powers at the state. district, sub district levels including ANMs for utilisation of untied funds at SHCs TECHNICAL INTERVENTIONS Institutional deliveries improved from JSY component of institutional 26% to 40.58% deliveries to be reported.

44% ASHAs selected. 40% of selected ASHAs trained in 1st module. TOT for 2nd and 3rd modules completed. Procurement of ASHA kits under progress Recruitment of contract staff, training and provision of equipments for operationalising BemOC/CemOC in progress Telephones functional at BemOC/CemOC. Repair/ renovation of OTs, labour rooms at CHCs/ BemOCs in progress.

Procurement and distribution of ASHA kits to be speeded up.

Training should be coordinated with other activities. Place trained manpower in facilities, where their skills can be utilised. All new constructions/ institutions to be eco friendly. Provide adequate toilets, waiting enclosures, etc. Build a nursing cadre in the state

- 126 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

TRAINING/ IEC/ NGO INVOLVEMENT MTP training for MOs in progress Provide quality MTP facilities at government institutions. Make people aware of this through IEC.

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, Need to evaluate this and other pilot with telephone connectivity and mapping schemes before scaling up. of pregnant women being piloted in 3 districts I50 blocks being developed as model blocks with all essential health care facilities 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 GOI MIES formats being adopted State to develop system for collection of data from SHCs/ PHCs at monthly Financial monitoring and reporting meetings. Feed data into computer at software developed. Training for PMUs PHCs/CHCs and report electronically at planned next levels. Data triangulation and validation Donor partners to support states in planned 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. OTHER ISSUES Some key recommendations of Goa conference to be actioned: o Maintainance of panel for recruitment o Timely confirmation, salary of contract staff o Integrate regular and contract staff o Design career progression for DPMU staff o CMHO to have power to sign cheques for expenditure approved by District Health Society

- 127 -

RCH II: FINDINGS OF 2ND JRM MAHARASHTRA Traditionally, Maharashtra has had good health infrastructure and hence expectations from the state are very high. However, Maharashtra has a long way to go. Shortage of skilled manpower and poor routine immunization are major challenges for the state. In addition, program and financial reporting is weak , although the state has a web based MIS in place. Financial utilisation during 05-06 has also been very low at 30 percent. Its high time for the state to work effectively and consistently in order to ensure improvement in health outcomes . Financial progress (2005-06) Allocation Release Expenditure Expenditure/ Release

Rs. 115.50 Crores Rs. 52.8 Crores Rs. 15.98 Crores 30%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE SPMU not in place as no one Try to take onboard ex MHSDP staff. applied for the posts except for Try to sign bond with DPMU staff to accounts ensure retention DPMs appointed for all the 33 Provide good working environment to districts; 5 accounts staff and 27 SPMU and DPMU staff. DEOs recruited, but not yet in position DAP for all the 33 districts ready and approved Cantonment areas of the state have a different system of provision of RCH services .

State needs to implement RCH II in cantonment areas by joining hands with defense department. Central Government would fix up meeting with defense department regarding the issue.

State and district health missions established FINANCIAL MANAGEMENT Irregularity in providing financial This is high priority. State must take reports to the center all necessary steps to ensure timely submission of financial reports for smooth flow of funds. TECHNICAL INTERVENTIONS Need to strengthen urban health program (40% of the population living in urban). Need more specialist doctors for Train doctors with multi tasking FRUs including SBA and anesthesia.

- 128 -

ACHIEVEMENTS/OBSERVATIONS Low utilisation of JSY (utilisation delivery is just 15%) All Districts and Sub District Hospitals are baby friendly hospitals State exploring possibility of nominating 7000 female pada workers as equivalent of ASHA.

SUGGESTED ACTIONS Identify medical colleges for organising training programmes. Need to rationalize staffing Need to reorient all the CMOs on various RCH II components including JSY

Health days conducted regularly Appointment of subsidized medical practitioners scheme is in process. (Operationalised in 24 remote villages) PIP for routine immunization prepared by identifying weak areas RKS established but not operationalised State going very slow on NSV

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 by already existing Arogya Sakhi in tribal area (provide ASHA training to AS) Ensure quality of health days through effective monitoring

Need to operationalise RKS immediately

Need to concentrate more on IEC of NSV Routine immunization has gone Try to hire vaccinator down drastically in the state Ensure proper fund flow for immunization. Ensure proper maintenance of cold chain. Ensure proper inspection and monitoring. TRAINING/ IEC/ NGO INVOLVEMENT MNGOs selected for all the districts except Mumbai, FNGOs from 28 districts selected Consultation from external agency for developing behavioral change and advocacy strategies (PCPNDT, JSY, referral transport, NSV and other RCH issues) On going training of LHV/ANM/SN on SBA Ongoing training on IMNCI
- 129 -

Need to properly mobilize and utilise the MNGOs

ACHIEVEMENTS/OBSERVATIONS training, NSV awareness camp and training, Mini Lap, CuT for MO.

SUGGESTED ACTIONS

State may explore the possibility of conducting EmOC trainings in collaboration with the donor partners INNOVATION Web based MIS in place Center has not received any web based MIS generated reports. Need to immediately look into generating reports from the MIS EQUITY AND ACCESS Districts are finalising village level referral plan for painting the names of vehicle owners who are willing to provide their vehicle for EmOC at designated rates. State is proposing to pilot referral transport scheme through Public Private Partnership in one block of each districts M&E AND TA REQUIREMENT State to systematically provide documentary evidence for achievement of core 13 indicators as specified in Enclosure 4 of the JRM Process Manual.

- 130 -

RCH II: FINDINGS OF 2ND JRM MANIPUR Manipur has been a late starter and the prevailing law and order situation has been a major constraint to implementing RCH II. The poor infrastructure and communication in the State further aggravates the situation. Strategic program planning and prioritization of interventions needs to be the focus in the forthcoming days. Conceptual clarity is crucial at all levels. Fund management needs to focus on utilization and accountability and compliance to prescribed norms of the GOI. Financial progress ( 05-06) Allocation Release Expenditure( Expenditure/ Release Rs.11.93 crores Rs.7.34 crores Rs.0.64crores 9%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE Delay in recruitment of SPMU and Required orientation of SPMU and DPMU. In SPMU, 4 positions are in place DPMU staff on a priority basis and all positions filled in the 9 DPMUs Review program management, need to streamline urgently State govt. needs to comprehend the concept and vision of NRHM Frequent changes of personnel at Directorate level. Lack of specialists in the remote districts and unwillingness of staff to relocate to remote areas State needs to review personnel policies ( with reference to posting of staff in remote, risky areas) Optimal utilization and rationalization of existing staff

FINANCIAL MANAGEMENT Low utilization of funds, especially for Streamline fund management JSY and untied funds for SC. system and ensure implementation of GOI guidelines Delay in fund flow to districts. Unable to open bank accounts in remote districts .. Funds managed by PHCs TECHNICAL INTERVENTIONS RKS registered in 4 district hospitals Orientation of RKS required on and 9 CHCs addressing hospital management issues Up gradation of CHC could not Activate and upgrade all CHC and materialize. Facility survey has been PHC to FRUs through appointment of completed trained, skilled staff IMNCI training of MO and paramedics has been initiated Proper planning required for IMNCI training

- 131 -

ACHIEVEMENTS/ OBSERVATIONS 570 ASHA selected in the State. Orientation training in process for ASHA Quality of care is poor in DHs. Delay in up gradation of hospital facilities. Poor health infrastructure in the districts

SUGGESTED ACTIONS Link ASHAs to health centers.

Focus on up gradation of all district hospitals at the earliest Up gradation and maintenance for infrastructure needs to given proper emphasis

TRAINING/ IEC/ NGO INVOLVEMENT Training of PRI and teachers , CBO More pro-active collaboration leaders have been carried out in districts required with NGOs to leverage program impact EQUITY AND ACCESS No plan for VGs of remote areas in Accelerate Implementation of Tribal place health program Tribal Health and urban health is yet to take off M&E AND TA REQUIREMENTS Lack of proper M & E system Mission Director needs to take initiative in monitoring progress of interventions OTHER ISSUES Insurgency, law and order situation, Concentrate program interventions is a concern in the State in insurgency free districts Quality of interventions needs major improvement

- 132 -

RCH II: FINDINGS OF 2ND JRM MEGHALAYA Meghalaya requires more concerted effort to overcome the slow pace of program implementation. Inadequate program management support at the district level has affected the pace of implementation at the lower levels. The major bottlenecks inadequate program planning, lack of basic information and awareness, motivation, understanding and involvement of program staff needs to be overcome at the earliest. Technical knowledge and assistance is required from GOI and RRC to accelerate the pace of implementation. Financial progress ( 05-06) Allocation (05-07) Release (1/4/05 to 30/6/06) Expenditure (1/4/05 to 30/6/06) Expenditure/ Release Rs.9 crores Rs.4.5 crores Rs.0.83 crores 18%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE In the SPMU , out of the 4 sanctioned Develop workforce management positions 5 positions have been filled up plan and speed up DPMU staff In the DPMU , of the 21 sanctioned recruitment positions , recruitment of 17 has been completed. Merger of health societies incomplete. Registration of management committees not complete District planning undertaken partially Lack of skilled staff at district level Enhance staff skill through capacity building trainings FINANCIAL MANAGEMENT Delay in flow of funds to districts Improve fund release and reporting at district level Late receipts of expenditure statements from districts TECHNICAL INTERVENTIONS Strengthening and up gradation of existing CHC to FRU is in process Transformation of PHCs and CHCs to FRUs needs to be taken up in a coordinated manner Train ASHAs by NGOs and RRC

So far 5020 ASHAs are in place. Training on for of 2nd batch of TOT Kits not available for trained ASHA Lack of adequate technical staff. Delay in joining services of technical staff

Ensure rationalization of existing manpower across all health facilities, specially in peripheral institutions

- 133 -

ACHIEVEMENTS/ OBSERVATIONS Rogi Kalyan Sammittee are not active

SUGGESTED ACTIONS Activate RKS to address major issues in hospital management

TRAINING/ IEC/ NGO INVOLVEMENT Collaborate with Church for The members of the Village Counsil community sensitization and Dorbar Shnong have been trained on awareness RCH II Disseminate IEC for enhanced awareness on RCH II activities

EQUITY AND ACCESS Insufficient health facilities in Explore alternatives (low cost, remote areas health facilities ) in remote areas through Church partnership No clear state strategy for reaching out to the marginalized, vulnerable population Select ASHAs from low performing districts and vulnerable communities

M&E AND TA REQUIREMENTS Staff lacks clarity on function and Urgent need for staff orientation utility of MIS. and training in MIS Assistance required from RRC for training of technical staff OTHER ISSUES No initiative on PPP Explore partnership with Army and Church

- 134 -

MEGHALAYA JRM VISIT REPORT Annual progress on financial & key RCH results indicators: State data: Population 2.6M, 7 districts, 25 CHCs, 101 PHCs, 400 SCs RHS data 2002-4 shows no or little improvement in indicators, especially immunisation rates Most indicators on the State datasets are scored very low Significant developments & progress overview since last JRM: All PMSU staff still not in place and there is a general lack of adequate awareness about RCH-2 There is a severe lack of specialised human resources for operationalising FRUs: a clear strategy to address the gaps is urgently required as no progress has been made in improving peripheral services Many ASHAs have been identified but still lacking in the worst performing districts and not yet oriented District planning is weak or non-existent with resulting apathy towards the potential opportunities in RCH-2 TA was requested by the State in the 1st JRM in several areas, but was not provided to an adequate degree

Key implementation issues & recommendations: Programme management: There is evidence of weak programme management support, especially at the district level, as the recruitment process has been slow with the remaining positions just about to be filled. In general, recruitment should be completed urgently, much more facilitation from the upper levels (GOI and State) to the lower levels is needed, more orientation is needed, and adequate training & guidance must be provided. There needs to be improved sharing of key documents (NPIP, SPIP, all guidelines, protocols, etc.) along with a series of workshops to facilitate complete understanding of the documents, and ongoing monitoring and supervision of understanding & consequent implementation at all levels. The merger of societies is not complete as separate societies are still operating for vertical programmes. The registration of management committees as societies at facility level is not complete; therefore, untied funds have not been released, staff cannot keep user fees at the facility, and there is limited awareness on how to spend these funds. District planning has not yet been fully undertaken but is planned for the rest of 2006. This activity has been contracted out to Medical Synergy. There has been very little progress in the work plan 2006-7 in the areas of civil works, facility improvement, and logistics improvement. Governance: The process of decentralisation seems to be limited, with delegation of authority unclear, and the district collector not involved in health activities. The village Darbars are actively involved in health, including selection of ASHAs. Technical: maternal health, child health, FP, RTI/STI, ARSH

- 135 -

The main constraint in improving service provision is the limited supply of human resources, with shortages of many specialists; therefore, facilities are not fully functioning. There is an urgent need to developing a comprehensive short and longterm plan for improving skills of health care providers, especially for providing CemOC. There is also a need for a comprehensive workforce management plan for career development. The workplan for training is very behind schedule, resulting in a delay in making FRUs functional. At the same time, in the facilities there are doctors and nurses available, many of whom have been in the same position for many years with little or limited upgrading of skills. This is demotivating and wasteful of their potential. Immunisation rates are very low; this needs urgent attention. IMNCI activities have also not yet started. There are many concerns about the overall quality of care, apart from the low skills level of staff. Supplies are not sufficient, e.g. drugs, reagents the supply is supposed to be delegated to the district level but this is not functioning well and facilities are running out regularly of basic essential medicines (e.g. paracetamol, antibiotics), and reagents. PHCs cannot even conduct basic haematology tests (Haemoglobin). Some facilities have water shortage and power cuts, and many have no telephone. Supervision of facilities is limited; therefore motivation is low. The Ganesh Das MCH hospital in Shillong is the main referral centre for obstetrics & paediatrics, however it is severely overburdened and crowded. This results in unsatisfactory practices such as separation of newborns and mothers, delay in initiating breastfeeding, and prolonged stays in hospital for patients who come from far away. The death rates were quite high in 2005-6; for 9,305 deliveries there were 38 maternal deaths, 220 neonatal deaths (<1 week), 130 post-neonatal deaths (1 wk 1 month), and 116 infant deaths (1mth 1 year). The unmet need for family planning is very high, so more emphasis needs to be given to improving access to FP methods, particularly in remote areas. Two counsellors for adolescent health have been appointed but no funds utilised. Training in RTI/STIs has not happened.

Innovations in service delivery (PPP, NGOs, Vouchers, health insurance, etc.) No PPPs are in place but there is a private sector and NGOs. There is a real potential for a PPP with the MCH hospital for a halfway house for women who do not need to be in hospital but waiting for delivery or recovering.

Access & equity: Facilities have been identified for upgrading, but there is slow progress. Selection process for ASHAs is good with active involvement of village Darbars, however, there are currently fewer AHSAs selected from poor performing districts. Demand generated by ASHAs will need due support from health system with additional inputs to most difficult areas.

Demand generation: JSY, BCC, IEC, Community Participation, etc. JSY implementation is varied, with lack of clarity on guidelines. IEC is weak and most planned activities in the workplan have not happened. The trend in early marriage needs urgent attention with specific activities for young married couples. The good network of Darbars could be more effectively used for this with NGO involvement.

Monitoring & Evaluation: MIS status, number of districts reporting monthly progress to state level, progress on institutionalising triangulation, quality assurance

- 136 -

There is irregular maintenance of registers, no 2-way communication between the levels, lack of clarity on forms, and limited communication means at facilities no telephones, computers at PHCs.

Convergence with HIV/AIDS and ICDS: Institutional arrangements, processes Little evidence of convergence with HIV/AIDS though there is good collaboration between ANMs and DWCD.

Technical assistance requirements: during the next 6 months and longer term Districts requested TA for all aspects of NRHM planning & implementation, State advised to complete orientation and training of programme management staff, to take additional support of NE-RRC, and engage more consultants as necessary.

Financial Details: (Summary of funds received, allocated and utilised) Remaining Sanctioned Received 2005-6 2006-7 2006-7 9.98 cr 3.96 cr Utilised by State 49.95 lakhs Disbursed to districts 49.98 lakhs Utilised by districts 38.05 lakhs Balance remaining 3.08 cr

Priority actions to be taken: (Key areas that require urgent action with timeframe and responsible person) 1. Result of all above is little progress on work plan, however State govt. felt that more success would be achieved in coming months as some initiatives had now been started 2. Need to ensure that all routine activities are taking place as well as new ones 3. Urgently need to put adequate TA in place to facilitate programme awareness, planning & implementation, particularly at district and block levels 4. Urgent attention needed to develop a comprehensive workforce management plan and ensure achievement of training plan, so that more skilled people are in place 5. Need to have some early successes to restore trust in health system and increase motivation of health staff and population, therefore, should focus on activities that will work quickly

- 137 -

RCH II: FINDINGS OF 2ND JRM MIZORAM Mizoram has made overall progress in program implementation. The State has strategically collaborated with the other players in the region like the Church, NGOs and Civil Society Groups to build awareness on the programme interventions. Some areas for improvement are fund management, reporting and monitoring systems. An outcome-oriented approach is required in program management. Financial progress( 05-06) Allocation Release Expenditure Expenditure/ Release Rs. 13.57 Crores Rs. 11.82 Crores Rs. 8.78 Crores 74%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE Merger of Health and Family Welfare Fast track recruitment of DPMU completed staff and ensure that they are trained. State and District health Committees have been set up State PIP has no plan for SPMU and DPMU. However , State has proposed DPMUs in 06-07 and recruitment is in process TECHNICAL INTERVENTIONS RKS formed in district hospital, but not Ensure RKS is fully functional and fully functional yet. monitor performance. So far 96 contractual ANMs have been appointed in urban and rural health centres . 666 ASHA/Link worker have been selected. Up gradation of 9 CHCs taken up. Upgradation of CHCs should be carried out in a coordinated manner

JSY implemented in all districts and institutional delivery under the same is 80% Deterioration in immunization coverage. Plan for target based immunization campaign

- 138 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

TRAINING/ IEC/ NGO INVOLVEMENT Training plan in place for SBA and IMNCI TOT completed for District Trainers and Medical Officers Two MNGOs functioning in 4 districts EQUITY AND ACCESS Outreach services held in remote areas in collaboration with Missionary hospitals M&E AND TA REQUIREMENTS Collaborate with donor partner to address capacity building needs OTHER ISSUES The State has initiated public private partnership

- 139 -

RCH II: FINDINGS OF 2ND JRM NAGALAND Nagaland has demonstrated considerable improvement since the last JRM. Program management structures are evolving and several innovations have been initiated. The State has moved ahead with a community-based approach to RCH II. However, the quality of program implementation is still below the desired standards. Program monitoring and capacity building are some areas that need major improvement. Information is still concentrated at the State level and has not percolated to the district and block levels. The State needs to adhere to the audit requirements and financial reporting standards. Financial utilization needs to be improved. Financial progress ( 05-06) Allocation Release Expenditure Expenditure/ Release Rs. 10.36 Crores Rs. 6.61 Crores Rs. 0.01 Crores 0%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE In the SPMU, of the 4 sanctioned DPMU staff recruitment should be positions, 2 are in place. In DPMU, of the completed urgently and trained. Focus 33 sanctioned positions, 22 are in place. on quality of staff Qualification of staff in Districts are not at par with GOI norms A round of orientation training has been done for the SPMU and DPMUs. State PIP prepared with DPMUs and approved by GOI Pro-active intersect oral collaboration with ICDS/Social Welfare/ Rural Development and Village Health & Sanitation Committees FINANCIAL MANAGEMENT Untied fund released to 325 subcenters out of 397 SCs. TECHNICAL INTERVENTIONS Four district hospitals functioning as Ensure that FRUs are fully FRUs functional. Explore training of MOs in West Bengal

- 140 -

ACHIEVEMENTS/ OBSERVATIONS Rogi Kalyan Sammitis formed in 10 district hospitals Selection of 731 ASHA completed TOT for ASHA (24) training completed for 3 districts in partnership with ICDS/RD/NGOs. 116 ANMs appointed, 60 for SCs without ANMs, 28 for 24 x 7 delivery services in PHCs, 28 for difficult and underserved areas. Training of MOs on IMNCI- 3 MOs Trained in Delhi for 7 days (from 20-27 Sept. 2006).

SUGGESTED ACTIONS Expedite RCH camps in districts

TRAINING/ IEC/ NGO INVOLVEMENT Induction and training of all new staff Plan training calendar and develop under RCH II have been completed training schedules Partnership with Churches / women Orient PRI, Village Councils and organizations / Hohos / Red Cross Womens wing on JSY and RCH II society Three MNGOs have been identified. EQUITY AND ACCESS Difficult to access health services in Sensitize Village Health committee remote areas on RCH II Identified Christian Mission Hospitals Utilize Village Health Committee for in remote districts (Impur/ Wokha/ Atoizu) wide spread reach to vulnerable with excellent infrastructure to establish communities in remote areas partnership for providing quality RCH/FP services. M&E AND TA REQUIREMENTS The District Health Mission to monitor TA required on TOT for ASHA compliance to Citizens Charter at CHC level Mid Course reviews and appropriate correction planned Lack of skilled technical staff Train technical/non technical staff through RRC -NE OTHER ISSUES Inadequate professional staff at every Identify and appoint professionals level from other States

- 141 -

RCH II: FINDINGS OF 2ND JRM ORISSA Orissa has taken a slow but steady approach to RCH II. NFHS 3 indicates significant improvement in outcomes: IMR: 65% ; full immunisation: 52 % and institutional deliveries at 36%. Programme management arrangements are in place , 83% of ANM positions have been filled, and extensive mapping using GIS is well underway in order to improve targeting and better utilisation of facilities. However, there are a number of concerns : The state has not purchased any drugs for the last 2 years and planning initiatives are yet to be translated into ground level impact especially in tribal areas. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 57.00 Crores Rs. 40.50 Crores Rs. 36.52 Crores 90 %

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE Need to ensure that programme management State and district health missions staff are effectively deployed through formed and health societies registered appropriate reporting relationships, clarification at and all districts. on job responsibilities and appropriate HRD Almost all positions in SPMU and DPMUs filled, and the majority trained. practices. Panel of candidates developed to fill vacant positions due to resignations. Block level programme managers being appointed.

50 % District Action Plans formulated

For District Action Plans SC/ST populations to be properly mapped

TECHNICAL INTERVENTIONS Tribal health camps are a key Camp approach to be used as shortcomponent of the strategy to deliver term measure only. Develop and act on a services. Even after all facilities have long-term plan. Use mobile medical vans for come up, full coverage of all population unserved/ underserved areas through facilities will not happen. State to develop procurement policy for procurement through private professional agency. 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.

- 142 -

ACHIEVEMENTS/ OBSERVATIONS TRAINING/ IEC/ NGO INVOLVEMENT High level of achievement in IEC/BCC activities

SUGGESTED ACTIONS

Health messages to be included in school text books Village level meetings of girls, adolescents to be conducted for effective IPC/ BCC State formulated a comprehensive IEC strategy in 2001, which could be revisited. Training for MOs, ANMs, LHVs in Train doctors, nurses in dealing with various areas including SBA training adolescents well underway. Subsequent to training ensure staff are in positions where the newly acquired skills are used. INNOVATIONS Handing over of facilities to private Handing over of facilities to be done players under PPP being piloted. State quickly level PPP policy being developed

State has developed extensive GIS maps and is working on superimposing data related to epidemic occurrence, demographic, socio economic parameters, on these maps to draw logical conclusions for formulating area specific RCH strategies. M&E AND TA REQUIREMENTS HMIS system well developed. Computers being installed in all PHCs/ CHCs

Need to demonstrate that GIS has led to improved decision making.

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 Facility surveys in 14 districts This should have been completed for all completed. district, by now.

- 143 -

Performance on 13 process indicators: Sr. no. RCH indicator 1. 2. % of ANM positions filled a. % of districts having full time programme managers for RCH b. administrative and financial powers delegated % of sampled state and district program managers aware of their responsibilities % of sampled state and district programme managers whose performance was reviewed during the past six months % of district not having at least one month stock of a. Measles vaccine b. OCP c. Gloves in the past six months? % of districts reporting quarterly financial performance in time % of district plans with specific activities to reach vulnerable communities % of sampled outreach sessions where guidelines for AD syringe use and safe disposal followed % of sampled FRUs following agreed IP and health care waste disposal procedures % of 24 hrs PHCs conducting minimum of 10 deliveries per month % of CHCs upgraded as FRUs offering 24 hrs EmOC services % of sampled health facilities offering RTI/ STI services as per the agreed protocols

Level of achievement 83 100 No 70 85

MOV/ OVIs 202 out of 243 planned 30 out of 30 appointed

3. 4.

21 out of 30 districts PMU training completed 25 out of 30 districts called for review meeting in the state and physical review held during district visit of SPMU As per buffer stock inventory report of district 30 out of 30 after appointment of district Accounts Manager 15 DPIP have been prepared where in tribal health & urban It is sampled during RI, catch up rounds PITS have been constructed in 13 districts CNAA CNAA 57 including DHQ, SDH and 3 medical colleges

5.

6. 7. 8. 9. 10. 11. 12.

0 0 0 100 50 100 40 30 64 50

- 144 -

Orissa State visit 4th -7th September 2006 A Joint Review Mission led by the Ministry of Health & Family Welfare, Government of India and joined by the development partners visited the State of Orissa during September 4-7, 2006 to review the progress in implementation of Reproductive & Child Health II Programme (RCH-II). The mission visited district Mayurbhanj and had detailed discussions with the CDMO and DPMU officials and had a wrap up with the District Collector Mr. Vijay K. Pandian. The mission visited the District hospital, Block CHCs, PHCs, SCs, RKS and the Panchayat and community representatives in the field. In Bhubneshwar the team had detailed discussions with the Directors and the SPMU. The mission had a wrap-up session with Mr. Chinmoy Basu, Principal Secretary, Health & Family Welfare, Dr B. C. Das, Director State Health Mission & Director SIHFW, Dr Usha Pattnayak, Director Health Services and other senior officials of Government of Orissa. The Mission members included Dr Sangeeta Saxena (Assistant Commissioner Child Health, GOI), Mr Susheel Pal (Consultant FMG, GOI), Dr Peter Berman (World Bank), Dr Sanjeev Upadhyaya (USAID), Mr Chris Murgatroyd and Ms Sabina Bindra Barnes (DFID). The team would like to thank the Government of Orissa for organising elaborate field visits as per the mission protocol and facilitating valuable and constructive discussions. Annual progress on financial & key RCH results indicators (Annex 1)

1. Significant developments & progress overview since last JRM:

The teams overall view, based on state-level reports and our field visits, is that Orissa has a moderately successful RCH program overall and is making significant effort and some progress in strengthening this program through RCH II. However, we feel that the substantive contributions of RCH II itself to improved outcomes on the ground (that is, the results of additional activities financed by the RCH II program in comparison to the baseline achieved in RCH II) are still quite modest. Orissa benefits from important additional technical and financial inputs from partners like UNICEF which contributes to RCH outcomes through developing IMNCI and Positive Deviance in some districts, but which is not yet part of RCH II. These have helped to maintain a positive trend. But achieving large scale improved outcomes will require greater outreach and quality in service delivery resulting from State efforts. If successful, this would also place a much greater burden of increased demand on public facilities that often are not in the best condition. In terms of indicators, Orissa has done well on indicators related to setting up the RCH II program, such as establishing the State society and PMU, and increasing some inputs, such as contractual staff, inception training, etc. It has done less well on operationalising improved service delivery, with the exception of significant improvements in immunisation and high levels of initial ANC. The lack of supply from RCH II to date of drugs and consumables to SCs is a matter of serious concern drugs like anti-malarials and cotrimoxazole, along with ORS, are important contributors to child health outcomes. We are also sceptical about the quality of safe delivery services available at many public facilities, including CHCs, despite the reports of some CHCs upgraded to FRUs, 24X7 services, etc. JSY implementation is sending mixed signals to mothers and families about safe delivery. Orissa has mobilised significant linkage between RCH and ICDS, but we didnt feel this had been picked up very much by the RCH II programme per se. 2. Key implementation issues & recommendations: a. Programme management: Structures for programme management seem to be in place with appointment and induction of key personnel at State level and District level, but

- 145 -

appointment of 9 DPMs is still pending and there has already been some turnover in key personnel (eg. District Accounts Managers). Block level management structures are still not in place, and the State Society doesnt have a gender or tribal coordinator. Also at the State level the present ED is due to retire in two months and has been given a joint charge. Vacancies of accounts staff at the Sub-District level (eg. In CHCs) will hamper the ability of RCH II to report effectively for use of funds at the lowest levels. All accounts posts need to be filled with consultation between State and District as necessary on availability of posts and deployment of appropriately trained personnel to perform key accounts functions. There also needs to be basic accounts training for ANMs: at present CHC staff assists with preparation of SC accounts for use of flexible funds which could lead to perceptions of conflict of interest in due course. There has been some management training for some DPMU staff, but members are waiting for further guidelines on specific roles and relations/coordination with the CDMOs. There is also a need for training at State level to clarify roles and reporting. Fifteen Districts plans have already been prepared, and others are under preparation. There is a need to ensure that these plans are properly synchronised with the State PIP, so that effort put in to preparing District plans is maximised. There is also a need to ensure that preparation of District plans under RCH II is coordinated with other planning exercises such as NRHM plans to ensure that there is no duplication or wastage of effort. There seems to be a confusion regarding the role of ZSS and RKS. The State needs to clarify the role of the two entities which should serve different functions (ie. one is facility based, and the other is responsible for the overall district health planning and implementation). There is no evidence of RKS having been registered yet. There is no evidence of District Hospitals being in a position to coordinate effectively with other public health services, or that the SPMU is in a position to promote greater coordination at this stage.

b. Governance: The nature of responsibilities at different levels within RCH II and the lack of authority for action at the District level (e.g. In terms of the District Magistrate being able to hold DPMUs effectively to account for delivery) has created a fractured accountability structure which may allow individuals to avoid responsibility for key deliverables. There is good evidence in Orissa that firm action from the Chief Secretary and DM in each District can help to ensure that responsibility is not avoided and that action is taken as necessary in SPMU and DPMU. Further down the accountability chain, it is not clear how ANMs are able to use flexible funds direct from GOI to SCs without support from CHCs, and how local authorities including PRIs, can play an effective role in monitoring use of funds. PRIs currently seem unable to do much more than spend small amounts of money as directed (eg. For malaria camps) without seeing a broader role for themselves in terms of oversight functions. At the State level, there seems to be little functional delegation from the Health Secretary to Executive Directors and the Directors to allow decisions and spending to respond to needs in the health system. There is some evidence of Committees at the State level chaired by the CS having a meaningful impact, eg. The NRHM Steering Committee, but there is no sense yet of

- 146 -

what role, if any, RCH is playing in helping to improve oversight. Other Committees set up to monitor individual aspects of RCH II activity at the State level represent another useful oversight mechanism and should be monitored over time to ensure that they are supported effectively in playing their role. There is a need to ensure that 2004-/2005 Audit recommendations are followed up promptly, and that SPMU and DPMUs cooperate with the preparation of 2005/2006 Audit reports. Full details of procurement under RCH II to date should be made available. Technical:

c.

Maternal Health: Health functionaries were observed paying attention to ANC and IMNCI with UNICEFs support in the district visited. However there is confusion about defining and declaring a facility FRU/CEmOC, BEmOC. GoI has sent guideline to pay Rs 500/- to any mother who delivers a baby even at home. There is no incentive for the mother to go to an institution to get Rs. 200/- more and this defeats the original purpose of the scheme ie encourage institutional delivery. The State needs clarity on payments to BPL/APL families under JSY. Further, the state has received the GoI guidelines of extending JSY to all mothers but has not disbursed the guidelines to the state health functionaries as they have calculated that its implementation will cost them an additional Rs 50 crore and their apprehension is that if they intimate their functionaries and then the money does not come, what will be their fate? There is only one anaesthetist for more than 2 million population in the district. Health personal shortage particularly the specialist is very acute. The State needs to find solutions to provide adequate clinical skills to available personnel to ensure quality services eg FRUs. The facilities for the management of RTIs/STIs are not adequate at block and district level. Child Health: Mayurbhanj is an intervention district for IMNCI strategy and has a strong presence of UNICEF. At district level, the results of IMNCI were found good. The project has rose confidence levels of the workers and they have started getting appreciation and respect from the communities they serve. Performance on immunisation was satisfactory in the district however Vitamin A supplementation was not very encouraging. Fixed Health and Nutrition Days (FHND) were found to be held regularly in the district. RCH kits for the Subcentres are not supplied for several months leading to unavailability of necessary drugs for common diseases like ARI, Diarrhoea and Malaria at Sub-Centres level. At state level, the operational strategy to roll out IMNCI is barely sufficient. State needs to use flexi funds to be able to engage trainers-cum-monitors in the district for making IMNCI implementation a success. Population Stabilisation: TFR and utilisation of spacing methods are encouraging however fall in sterilisation rate is worrying; only 2 NSVs were conducted in district in last 1 year. ARSH National adolescent health guidelines came to the State after submission of State PIP. It needs to be now integrated with the State PIP. Training: The State has prepared a training calendar for the year 2006-07. Need for availability of inputs, such as critical staff at all levels including training maternal trainings off the ground. Bio-medical Waste is another area where capacity building efforts are required. IP measures were not observed. Miscellaneous: Team observed that some of the drugs, which are constantly required at DHH level, are not available; on the other hand, these drugs are lying unutilised at New PHC

- 147 -

level in abundance. Supplies, in general are irregular and not adequate. There is a need of AMCs for purchased equipments, as maintenance and repair of equipment is a big problem. There is a lot of improvement in the health care facilities at DHH in last one year; still lot is required to bring it to IPH standards. Cleanliness and Biomedical Waste Management are some of the areas for focus. Recommendations:

Ensure adequate technical human resources at all levels Doctors, Nurses, ANMs etc. Assure adequate supplies and inputs to peripheral facilities, especially sub-centres; there is a need to re-appropriate distribution of drugs in districts. Bring permanent contraceptive methods (sterilization) back to agenda; dialogue with Orissa Service Medical Officers Association in this regard2 Strengthening of technical capacities at state, district and sub-district level through continued technical support(training, skill enhancement); also to reinforce the ongoing coordination mechanism between State Health Society and State Health Department. Incorporate ARSH component in revised State PIP.

d. Innovations: The State has handed over one PHC to an NGO and to make it viable has also handed over immunisation and other reach out services in that area. The State is going rather slow on this and could consider handing over a number of PHCs to a private partner with flexibility of moving staff around. The State also has plans to contract out 20 sub-centre on a pilot basis across the State. Here too it would be worthwhile to contract out several SCs to a partner rather than one to make it more economically viable. e. Access & equity: Orissas large ST population probably means that the poor do benefit from improving services overall. But project reports and field observations did not indicate much pro-activity to increase access by the poor and vulnerable communities. No significant tribal plan is in effect. The mission observed during the district visit, that additional ANMs were often filling existing vacancies rather than being placed in remote areas. There does not seem to be much explicit identification of under-served areas and populations or of targeting additional resources to priority groups. An innovative exercise is underway to use GIS to map access to providers and facilities, which could provide a basis for better targeting of resources. Plans to target the urban poor are also underway. Recommendations: Use GIS, other data to set priorities in targeting inputs to blocks with worst health indicators. Consider flexible funding and approaches to increasing coverage, access, quality in more remote areas, where existing model of fixed facilities may not be most effective Develop monitoring of distribution of services and outcomes in vulnerable communities

f. Demand generation: No clear cut BCC strategy was evident. There was a reference to one lakh posters printed and distributed for JSY. However the districts informed the team that they had not received any posters under JRY. Focus is on organising health melas and IPC. It was claimed that community participation is being ensured; SHGs and PRIs are being involved in CNA. During the field visit however this was not evident.
2

Recently a local court in Orissa fined Rs. 50,000/- as compensation for a failed tubectomy and a similar case is pending in court. These developments are leading to low motivation amongst service doctors. - 148 -

g. Monitoring & Evaluation: Progress on M&E has been slow. Based on state reports in part this is due to changing signals from GoI. Clear guidance has not been received on changes needed in RCH HMIS. The advent of NRHM has added additional technical dimensions to this and the State still awaits a GoI package on what is expected for the NRHM HMIS, at least for PHC and above. GoO noted that they are working on a comprehensive sub-centre format that is designed to meet the States needs and objectives and that they may go beyond the recommended GoI package when it is received. They expect this to be done in about one month, but it will still need state government approval. The districts, such as Mayurbhanj, which receive significant UNICEF assistance for IMNCI are reporting and using data at district, block, and facility level using the effective coverage model. We did not perceive that significant extra efforts are being made in other areas to obtain and use HMIS data. We also had no evidence of significant additional efforts being made to measure quality or use of data in quality assurance activities. No client satisfaction survey has been done. Recommendations: Use of data should be given greater priority may be too much focus on establishing standardised reporting Strengthen supervision mechanism Better use of data requires appropriate processing at block and district level and training of teams to regularly review and discuss results. Also requires flexible support to respond to needs. State should develop models for this. Some examples already there in UNICEF-assisted districts. h. Convergence with HIV/AIDS and ICDS: There is good evidence of convergence between ICDS and RCH II. Regular meetings of the CDPO and CDMO with the DM can help to ensure consistent activity between the programmes, and that ANMs and Anganwadi workers cooperate effectively at the lowest levels of respective programme delivery. Further efforts by DMs to encourage this will be beneficial. At the district level the officials needs more clarity on convergence. There is little evidence of convergence between DoHFW and other departments at either the State or District level. Individual Districts with tribal populations are aware of initiatives to support tribal communities through maximising available funding from different departments, but it is not yet clear how this is helping to improve access to health care in practice under RCH II for those communities. There is no evidence of convergence between RCH II and NACP. Convergence at District level will be critical for effective coordination of services eg. condom supply and support services for treatment of STIs. This may be particularly important in Orissa with the network of roads passing through the State to/from Kolkata, Mumbai and Chennai.

i. Technical assistance: State is doing numerous activities on various RCH related issues. Technical Assistance would definitely improve the outcome of interventions. However there is question if the state has the capacity to consume TA at this point of time.

3. Financial Details: (details for FY 2005-06 in Annex 2)

Fund Releases during FY 2006-07:

- 149 -

Orissa State Health Society (SHS) had received Rs 49.50 Crores under RCH II as on 03/07/06. Of this, SHS released only Rs 5.65 Crores to the districts and towards various activities up to 06/09/06 as indicated in the table below:

S. No 1 2 3 4

Date of Release 30/06/06 02/09/06 02/09/06 05/09/06

Activity Loss of wages Salary and OE of SHS JSY IEC Total

Amount (in Cr) 0.54 1.14 3.67 0.30 5.65

Thus, over a period of 2 months, State Government could release only 11% of total funds received under RCH Flexible pool to the districts. As seen from the date of releases, most of the releases have taken place only during the first week of September 2006. As most of the expenditure takes place at the implementing units below the districts the expenditure levels will remain low. Fund Releases and Flexibility to the Districts: It was noted that all the funds released to the districts are tied funds. That is, the funds are being released under each activity, such as, under JSY, Sterilization, for ambulance support, contractual salary etc. This defeats the whole purpose of releasing the RCH funds under Flexible pool. Infact, the Flexible pool concept exists only at Govt. of India level and not below it. Therefore, the concept of flexibility as per the need is still not available at the districts and below. The State continue to release funds in the same fashion as in RCH-I. It was also noted that the funds released to the DHS is not in accordance with the District Health Action Plan. Infact, there is a mismatch between the funds released to the Districts and District Heath Plan. No flexibility to districts to spending on specific activities identified as per the district needs. So, though funds are available but DHS cant spend without guidelines from DHFW/SHS. Some of the activities which are becoming major bottlenecks are: 6 IMNCI trainers cum monitors (@ Rs 7 to 8,000 per month) lying idle as UNICEF has stopped the support. Could have been hired if the flexibility were provided. Meeting mobility support for MO (Rs 500/- pm). UNICEF has been giving mobility support of: SMO Rs 500/-, BEE Rs 400/-, LHV & Male Supervisors Rs 300/Buying various common drugs (when in shortage), Meeting other contingency needs of the PHC/CHC etc

- 150 -

Another fact, noticed was that, the funds were released for activities for which there were no guideline and funds were not available for activities for which guidelines existed. For example: Mayurbhanj district was released Rs 46 Lakhs (out of release of Rs 74 lakhs in March, 2006) for hiring ambulances for which there was no guidelines. On the other hand, there was a demand for JSY but no funds were available under JSY. Bottleneck in the Fund Flow: It was noted that funds were almost exhausted/spent under JSY and untied fund at the subcenter level; but, the SoE from PHC to Blocks and from Blocks to the Districts had not reached. As a result, SHS was withholding the release as the SoE or Utilisation Certificates. This movement of vouchers, SoE and Utilization Certification had been a major roadblock in the timely fund flow to the districts. Recommendations: State Government may take immediate steps to put in place the Block Programme Mangers or Block level Accountant so that the movement of these records is facilitated leading to timely flow of funds. 4. Priority Actions (September 2006-January 2007) Issue Actions Governance/ Fill the remaining positions stipulated in Programme the PIP for the SPMU, DPMUs. management/ Expedite the recruitment and training convergence for block management units staff. Sustain stability and capacity of technical staff at the State and district level Delegation of authority across all levels

Responsible body DFW/SPMU/ DPMUs DFW/SPMU/DPMU PS, DHFW

Time frame

PS, DHFW

Complete the orientation training for DHFW/SPMU/ DPMU as well as the departmental District PMUs staff. Expedite appraisal of the 15 DAPs and prepare the remaining DAPs so that resources can be appropriately allocated to the most needy areas Set priorities across different activities State/Districts in the PIP Register the newly formed RKS Clarity on convergence at district level needed Supply of drugs to be streamlined at all State/Districts levels, especially at peripheral level (contingency funds provided to ANMs are being utilised to this purpose) Orissa SHS along with the DFW to DFW/SHS immediately plan for releases to Districts and other implementing units. State/Districts

Financial management

Sept 2006

- 151 -

Issue

Actions Responsible body The releases to Districts should also be DFW/SHS as flexible pool releases (on the lines of GOI), as per the District Action Plan Need for adequate financial powers. delegation of Health Secretary

Time frame Sept 2006

Training of Accountants in PHC/CHC, DPM and ANMs in Sub-centres by District Accounts Manger. Technical Maternal Health Clear and one definition of facilities e.g. MH Division CEmOC, BEmOC, 24X7, FRU etc. Commence Training to MOs on Director Anaesthesia, MVA, Basic & CEmOC SIHFW/DHS Provide more clarity on the JSY MoHFW scheme and stick to primary objective of scheme i.e. institutional delivery Child Health Finalise implementation of operational DFW guidelines for IMNCI to be used by the State and District Programme managers Develop a strategy for engaging private DFW/SHS providers to enable them using IMNCI protocols and also dialogue with department of WCD to ensure their participation Finalisation and dissemination of DHS manual for quality assurance in sterilisation. Adequate attention to Sterilisation; DHS dialogue with Orissa Service Medical Officers Association Trainings SA of GNM training centres in the States facing shortages for staff nurses and develop a road map Finalise calendar of activities to DFW/SHS promote Infant & Young Child feeding and Micro-nutrient supplementation training Training on Quality Assurance & Bio- SIHFW medical Waste Management Innovations Need to scale actions on PPP and SHS/DFW other innovations in the State PIPs.

October 2006

Sept 2006

Family Planning

July 2006

- 152 -

Issue Equity Access/ Vulnerable Groups

Actions Responsible body & Collect and collate key indicators disaggregated by sex, SC/ST, District DFW/SHS and Block to identify who are the most vulnerable, where they are and what are their specific/additional needs. Use GIS, other data to set priorities in SHS targeting inputs to blocks with worst health indicators, greatest need. Provide flexible funding and approaches to increase coverage in remote areas Deploy additional ANMs to remote DFW/SHS areas rather than filling existing vacancies

Time frame

Develop and integrate urban health and tribal health plans in the overall PIP. M&E/ focus on Finalise the CNAA format for the Sub DFW/SHS outcomes centre level Train the personnel in use of new formats. Initiate capacity building for community monitoring State to organise the following training Director immediately SIHFW/DHS Anaesthesia training for the MO Refresher training for SBAs State to develop a comprehensive BCC Director SIHFW plan IEC materials to be disseminated to the Director SIHFW district e.g. printed posters for JSY TA Scope of TA is immense; State to DHS/SPMU prioritise areas/issues

October 2006

Training/BCC/ NGOs

- 153 -

Annex 1 Progress on 13 identified process indicators Sr. No. 1 2 RCH INDICATOR % of ANM positions filled a. % of districts having full-time programme managers for RCH b. Administrative and financial powers delegated % of sampled state and district program managers aware of their responsibilities % of sampled state and district programme managers whose performance was reviewed during the past six months % of district not having at least one month stock of g. Measles Vaccine h. OCP i. Gloves in the past six months? % of districts reporting quarterly financial performance in time % of district plans with specific activities to reach vulnerable communities % of sampled outreach sessions where guidelines for AD syringe use and safe disposal followed % of sampled FRUs following agreed IP and health care waste disposal procedures % of 24 hrs PHCs conducting minimum of 10 deliveries per month % of CHCs upgraded as FRUs offering 24 hr EmOC services % of sampled health facilities offering RTI/STI services as per the agreed protocols M&E Triangulation Level of achievement 83 100 No 70 21 out of 30 districts PMU training completed 25 out of 30 districts called for review meeting in the state and physical review held during district visit of SPMU As per buffer stock inventory report of district 30 out of 30 after appointment of District Accounts Manager 15 DPIP have been prepared where in tribal health & urban It is sampled during RI, catch up rounds PITS have been constructed in 13 districts CNAA CNAA 57 including DHQ, SDH and 3 medical colleges MOV/OVIs 202 out of 243 planned 30 out of 30 appointed

3 4

85

0 0 0

6 7 8 9 10 11 12 13

100 50 100 40 30 64 50

- 154 -

Annex 2 Fund Flow Statement for FY 2005-06: Programme Funds Allocated (PIP for FY 200506) RCH Flexible 57.00 pool A. S. No. A.1 A.2 A.3 A.4 A.5 A.6 A.7 A.8 A.9 A.10 Total Scheme Maternal Health Child Health Family Planning Services New Initiatives/Innovations/Interventions Urban RCH Tribal RCH Institutional Strengthening Training BCC/IEC Programme Mangement RCH Flexible Pool Funds Released during FY 2005-06 40.50 Expenditure incurred during FY 2005-06 36.52 % of allocated amount accessed 71% % Utilization of Funds Released 90%

Scheme wise break of RCH Flexipool for FY 2005-06: Expenditure 9.51 0.34 4.10 1.25 1.05 0.35 12.23 2.56 1.71 3.41 36.52 % of RCH 26% 1% 11% 3.5% 3% 1% 33.5% 7% 5% 9% 100%

- 155 -

Annex 3 Abbreviations ANM ARSH ASHA BCC BEmOC CDMO CHC CEmOC DAP DHH DHS DFID DM DPM DPMU ED FMG FRU GoI ICDS IEC IP IPC IPHS IMNCI JSY MIS MH MO MVA NACP NGO NRHM PIP PHC PPP PRI QA RCH RKS RTI/STI SBA SC SIHFW SHS SMPU SoE TA UNICEF USAID WCD Auxiliary Nurse Midwife Adolescent Reproductive & Sexual Health Accredited Social Health Activist Behaviour Change Communication Basic Emergency Obstetrics Care Chief District Medical Officer Community Health Centre Comprehensive Emergency Obstetrics Care District Action Plan District Headquarter Hospital Director Health Services Department for International Development District Magistrate District Programme Manager District Programme Management Unit Executive Director Financial Management Group First Referral Unit Government of India Integrated Child Development Services Scheme Information, Education & Communication Infection Prevention Inter Personal Communication Indian Public Health Standards Integrated Management of Newborn and Childhood Illnesses Janani Suraksha Yojna Management Information System Maternal Health Medical Officer Manual Vacuum Aspiration National Aids Control Programme Non Governmental Organization National Rural Health Mission Project Implementation Plan Primary Health Centre Public private partnership Panchayati Raj Institutions Quality Assurance Reproductive & Child Health Rogi Kalyan Samiti - Reproductive Tract Infections/Sexually Transmitted Infections Skilled Birth Attendant Sub Centre State Institute of Health & Family Welfare State Health Society State Programme Management Unit Statement of Expenses Technical Assistance United Nations Childrens Fund United States Agency for International Development Women & Child Development

- 156 -

ZSS

Zilla Swasthya Samiti

- 157 -

RCH II: FINDINGS OF 2ND JRM PUNJAB Punjab has shown an increase in NSV rates and has achieved 1 NSV trainer per district. An increase in Institutional Deliveries and Antenatal Care is also reported. However, the overall pace of progress on activities has been extremely slow. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 29.00 Crores Rs. 17.42 Crores Rs. 5.97 Crores 34%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS GOVERNANCE SPMU is in place. Block level PMUs being set up. Speed up recruitment of DPMUs. SUGGESTED ACTIONS

FINANCIAL MANAGEMENT/PROCUREMENT 54% of JSY funds released to date have been utilised. Any clarifications on procurement need to be done by the governing body of the society. Involve PHS Corporation. TECHNICAL INTERVENTIONS IMNCI training started. Step up pace of trainings. Increase in NSVs. Have 1 NSV trainer/district. 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. Focus to be given for monitoring sex ratio at birth, enforcement of PNDT, and gender issues. TRAINING/ IEC/ NGO INVOLVEMENT 6 districts covered by 3 MNGOs ToTs done for faculty of Anaesthesia for training of MOs. ToTs done for MOs and paramedicals for gender mainstreaming Several RCH I trainings are still being conducted. Increase pace of trainings based on the new modules.

- 158 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

M&E AND TA REQUIREMENTS 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 . Data should be provided on the 13 process indicators : refer Annex II of the JRM Process Manual.

- 159 -

RCH II: FINDINGS OF 2ND JRM PONDICHERRY Pondicherry has faired well in terms of RCH II process indicators. The UT has a good governance system in place. The major challenge is to sustain performance. Good performance against indicators can be largely attributed to the small and manageable population of the UT. In such a situation Pondicherry shouldnt take the liberty of skipping activities in their work plan ( there are many budgeted activities where the utilisation has been nil). Financial progress (2005-06) Allocation Release Expenditure Expenditure/ Release

Rs. 1.00 Crore Rs. 0.87 Crore Rs. 0.92 Crore 106%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/OBSERVATIONS GOVERNANCE SPMU and DPMU in place Public Health System functioning well District missions in position Problem in recruiting regular doctors SUGGESTED ACTIONS

The issue may be raised with the state government.

FINANCIAL MANAGEMENT Funds utilisation as per the work Funds utilisation and work plan needs plan to be synchronized. TECHNICAL INTERVENTIONS FRUs operational for Basic & EmOC 98% Institutional Deliveries 98% Child Immunisation Rubella Vaccination introduced in Adolescent Health VCTC & RTI/STI Services available INNOVATION Setting up of e banking system is in process

- 160 -

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

Level of Achievement 95 100 100 100

0 100 0 100 85 25 0 100 100

6 7 8 9 10 11 12 13

- 161 -

RCH II: FINDINGS OF 2ND JRM RAJASTHAN Rajasthans performance is good: RCH II is high priority for the senior most levels in the state (Maternal health/RCHII highlighted in the states budget speeches; . Chief Minister has also written to each sarpanch re importance of JSY.) , strategies have been systematically formulated and several innovations eg Gram Sat, malnutrition centres, etc are underway. There is, perhaps, a need to speed up implementation. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 87.50 Crores Rs. 40.00 Crores Rs. 22.72 Crores 57%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE SHS/DHS constituted at state Some key observations of Goa and all districts. 100 professionals in conference on this matter could be actioned: SPMU/DPMUs inducted. High early confirmation of contract staff; integrate turnover of staff. Difficulties in old and new staff through appropriate adjustment between contract and reporting system and clear job regular govt. staff, especially in case responsibilities. State to spell out equivalent of accountants. levels of contract staff in government hierarchy. SIHFW has been designated as the Human Resource Management State Human Resource Management Agency. 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. FINANCIAL MANAGEMENT Delay in merger of societies at Decided in the Goa conference that to districts has hampered funds flow. simplify financial procedures and avoid District officials unhappy due to delays, DCs to approve the expenditure removal of cheque signing authority. under various heads, but cheque signing authority for the approved amount to rest with CMHO/ CS. States to communicate this to the districts.

- 162 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

TECHNICAL INTERVENTIONS Frequent modifications in JSY JSY guidelines being modified in order to guidelines creating difficulties in simplify implementation at grass root level. communicating at the lower levels. Promote JSY at village level to encourage Thereby JSY implementation institutional deliveries; conduct workshops at suffering. IEC campaign for JSY put villages, blocks, in functional institutions; on hold make JSY a political issue at community level. JSY compensation being increased to support and empower women. Provide post operative care for mothers through effective tracking ANMs claiming home deliveries under JSY. Monitoring to be strengthened at SHCs.

Several FRUS do not have blood storage facilities.

Red Cross has assured support in providing blood storage facilities in all districts. State to work towards forming partnership with Red Cross Integration of AYUSH to increase choice for people. Roles of AYUSH and allopathic practitioners to be clarified.

AYUSH practitioners in 360 institutions. Recruitment of AYUSH practitioners underway.

TRAINING/ IEC/ NGO INVOLVEMENT Master trainers trained for After training the functionaries to be Anaesthesia, SBA, IMNCI, etc. posted such that they provide services in the District level training for MOs, ANMs area of training. Computer data base of has begun. Resource centres for trained persons to be maintained and used SBA, ASHA established. Heavy for their posting. training load in the state/ districts. Medical colleges to be involved in Lots of modules in the process of training. SBA, EmOC training to be included development, adaptation. in MBBS curriculum.

TBA training underway.

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.

- 163 -

ACHIEVEMENTS/ OBSERVATIONS State BCC plan finalised, rationalisation of posts in IEC bureau underway, engagement of professional agency planned. Separate release of IEC funds by GOI causing problem.

SUGGESTED ACTIONS From next year IEC money to be disbursed under common flexible pool. 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.

INNOVATIONS 3 colour cards for tracking Next level of institution for referral patients referred from SHC, PHC and services to be identified for all facilities. The CHCs referral institutions to be prepared to receive referred cases.

Panchamrit scheme in hard to reach areas covering child care, ANC/PNC and family planning awareness Gram Sat studio established, being equipped for providing training at PRI level JSY helpline piloted in 1 block through PPP. To be upscaled to all districts. 42 patients provided timely care through use of this.

Home visits by ANM/ AWW for new born care to be carried out.

EQUITY AND ACCESS Supply of ASHA kits underway State to identify the proportion of SC/ STs among ASHAs ASHAs to be compensated for identified services. HMIS formats revised. M&E AND TA REQUIREMENTS State to provide documentary evidence for achievement of core 13 indicators as specified in Enclosure 4 of the JRM Process Manual . Data should be provided on the 13 process indicators: refer Annex II of the JRM Process Manual.
- 164 -

OTHER ISSUES Decision on state corporation on

Donor partners to assist states with

ACHIEVEMENTS/ OBSERVATIONS the lines of TNMSC pending. Resources for recurring costs of the corporation required under NRHM

SUGGESTED ACTIONS strengthening procurement and logistics systems. Army has proposed to support health care through running PHCs, providing doctors on part time basis at health facilties, training of health department staff, helping women in distress through counselling. States to make use of the offer made by the Army.

- 165 -

RCH II: FINDINGS OF 2ND JRM SIKKIM Sikkim s level of progress is disappointing. Various constraints in the State like lack of skills in program planning and management, non-availability of specialists and training facilities has adversely affected progress. There is an urgent need to evolve imaginative solutions, effectively plan and monitor. District and block level management systems need to be strengthened. Dissemination of information and creation of awareness on new program interventions at the community levels needs to be high priority. Financial progress ( 05-06) Allocation Release Expenditure Expenditure/ Release Rs. 1.82 Crores Rs. 1 Crores Rs. 1.03 Crores 103%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE At the State level only the finance Need to source qualified personnel manager and data assistants are through media and other networks. recruited. The other positions are filled by Prioritize recruitment of Programme personnel from the State Health Managers . Directorate. In the DPMUs 8 out of 12 positions have been filled. However, the DPMs are not in place. TECHNICAL INTERVENTIONS Lack of specialists for placement in FRUs. 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 CHC. Ensure that all inputs are coordinated and lead to delivery/ utilization of services Prioritize implementation of JSY and health camps Capacity building of ANMs needs to focused at the earliest

Up gradation of PHC and CHCs initiated. Estimates prepared for new born corner in the CHC JSY has been implemented in the districts. Institutional delivery is low at 43% Twenty six additional ANMs appointed

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS

- 166 -

TRAINING/ IEC/ NGO INVOLVEMENT Delay in training due to lack of TOT and training centers Comprehensive training plan to be developed . West Bengal may be explored for training facilities

IEC prepared for awareness on program activities Process on to identify MNGO EQUITY AND ACCESS No initiative to identify and plan for Formulate plans for service delivery VGs in remote areas through NGO/ CBO partnership Difficult terrain makes it a constraint in accessing health care in remote areas M&E AND TA REQUIREMENTS Program monitoring system not in Develop monitoring mechanisms place for smooth flow of information to and from districts and blocks OTHER ISSUES Delay in hiring of contractual Identify reasons and take employees appropriate action. This should be priority.

- 167 -

RCH II: FINDINGS OF 2ND JRM TRIPURA Tripura has initiated steps to establish management structures at the district level including operationalization of DPMUs. However, implementation of activities is slow due to lack of poor infrastructure and technical know how at the lower levels. The remote location of some districts act as an impediment in ensuring access to essential services to the vulnerable communities; this needs to be addressed urgently. Capacity building needs for technical staff should be prioritized. Systematic program monitoring and evaluation will improve program outcome. Financial progress ( 05-06) Allocation Release Expenditure Expenditure/ Release Rs.9.67 crores Rs. 6 crores Rs.2.02 crores 34%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE Recruitment of 3 SPMU staff Ensure capacity building of existing completed. Recruitment of 12 sanctioned staff and equitable distribution of the positions in DPMU completed same in district and block levels District RHM formed in July 2005. State Health and FW Society formed and registered in January 2006; merged. 4 District H&FW Society constituted in January 2006. Registered & meeting regularly. FINANCIAL MANAGEMENT JSY funds release and 100% Ensure receipt of UC s from utilization districts Rs.3.76 crores released to districts

TECHNICAL INTERVENTIONS Upgradation of 6 DH and 10 CHC in Emphasize training for multiskilling process of doctors and capacity building of other technical staff to ensure activation of On going upgradation of 5 DHs for FRUs FRU 80% ANMs in place 1229 ASHA/ Link workers in two districts Under JSY 1429 deliveries conducted of which 761 are institutional deliveries (53%) Identification of 640 dais done for SBA training Dai training should be seen as an interim arrangement ; the emphasis should be on delivery by SBAs. Training of ANM and ASHA especially on SBA to be done at the earliest

- 168 -

RKS formed in all 4 districts

Ensure community participation in RKS and monitor progress of the same.

Doctors trained in NSV. Low Utilize innovative IEC techniques community interest TRAINING/ IEC/ NGO INVOLVEMENT IEC and BCC taken up in various Engage NGOs in IEC and BCC forms Community awareness campaigns campaigns taken up through innovative means Slow pace of training programs due to lack of training facilities Explore training facilities beyond the State in coordination with RRC

EQUITY AND ACCESS Appraisal completed forr Urban slum Required sustainable plan for project. . Municipal Counselor trained on placing skilled work force in out of RCH II access areas No plan for identifying the Special plans need to be disadvantaged population formulated for the vulnerable groups M&E AND TA REQUIREMENTS Inadequate procurement related Required assistance from GOI on authorized agencies procurement MIS system not in place Assess training needs and develop plan accordingly OTHER ISSUES Required additional funds from GOI for vehicles and security personnel in remote areas

- 169 -

RCH II: FINDINGS OF 2ND JRM UTTARANCHAL The state has taken various steps to put the required building blocks for RCH II in place, but needs to fast track implementation in order to improve delivery and utilisation of RCH services. The limited availability of manpower should be addressed through eg multi-skilling and PPPs. Outputs need to be closely monitored through routine reporting formats and field visits. The institutional structures should be made fully functional, and given freedom for using the resources available. District Health Societies should meet regularly and RKS should be given freedom to use the money collected. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 13.00 Crores Rs. 7.46 Crores Rs. 4.28 Crores 57%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS SUGGESTED ACTIONS GOVERNANCE SPMU/DPMU staff recruited, and Same activity should not be given first round of training through duplicated. Effectively plan usage of SIFPSA. Further training to be funds from different sources. organised through GOI funds. 6% RCH funds insufficient for covering costs of block programme managers. Use 6% of NRHM funds for this.

FINANCIAL MANAGEMENT Reasons for low utilisation not clear Utilisation of only Rs. 15 lakh by the st state in 1 quarter of 2006 TECHNICAL INTERVENTIONS Pharmacists to be posted at SHCs to States should support MPW (M) as all replace MPW (M). tasks required at SHC cannot be done by ANM. Availability of pharmacists at PHCs to be ensured. ASHA like workers to be selected for State should reconsider. Differential 6 blocks in border districts. To get higher compensation to similar workers can incentives compared to ASHAs create legal complications. Money required for GNMTC 90 % ANM positions filled Proposal for GNMTC submitted by HIST to be looked into. Panel of wait list candidates to be maintained for later use.

- 170 -

ACHIEVEMENTS/ OBSERVATIONS Selection, training of ASHAs and procurement of ASHA kits in progress. Requirement of ASHA training material in Hindi.

SUGGESTED ACTIONS State to expedite procurement of ASHA kits through delegation of procurement powers to districts. Procurement and distribution of ASHA kits to be completed by December ASHA training material modules translated by other states (MP) to be shared. GOI to translate other modules for dissemination to Hindi speaking states.. Explore opportunities under PPP Conduct training for multi skilling of doctors

Shortage of specialist doctors and other technical staff such as lab technicians

TRAINING/ IEC/ NGO INVOLVEMENT FOGSI training for SBA, Anaesthetists to be scaled up for making FRUs functional. Enter into partnerships with neighbouring districts in UP, as institutions for SBA training limited in the state State to seek help from Indian nursing council for training of nurses. Need to develop nursing cadre in the state. Orient government staff in NRHM EQUITY AND ACCESS Under the SISPSA project, a pilot Focus on institutional delivery/JSY initiative, Voucher System (on the lines of through IEC. Chiranjeevi Yojana) in Haridwar. Mobile Health Services in six districts.

Health Cards to BPL families

M&E AND TA REQUIREMENTS MOs visit SHCs on Wednesdays for Monthly health days to be monitored. outreach camps. ANM attends health & Donor partners to provide assistance in nutrition day at AWC on rotation basis monitoring OTHER ISSUES TA for District Action Plan under State to seek assistance from USAID NRHM required for development of DAPs. To follow procedure given in process manual for State RCH II plan has been DAP. consolidated from district plans. State to allocate some untied funds to districts under RCH flexi pool.

- 171 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS RKS money should not be used for non plan expenditure of the state. District hospitals to be made fully functional Enter into partnership with Red Cross for provision of blood at FRUs. Focus on long term measures through HRD plan. Coordinate training and posting of trained manpower in required facilities. Organogram including contract staff to be developed. Level of contract staff vis a vis regular staff to be addressed. Delegate administrative and financial powers at appropriate levels Develop operational plan addressing sustainability for running of mobile vans for each district under NRHM Empower RKS to recruit nurses

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

Level of Achievement 52 100 100 93 0 0 0 100 100 42 20 27 17 --

6 7 8 9 10 11 12 13

- 172 -

RCH II: FINDINGS OF 2ND JRM UP UP has embarked on RCH II programme with almost a clean slate. Since the institutional mechanism in not completely in place, the state can innovatively try to use the private doctors and other skilled manpower. Infrastructure strengthening should be matched with effective manpower planning to make the infrastructure fully operational. District action plans should be used to reflect local issues and solutions. Programme management structure needs to be revamped through state, district and block level management support. Financial progress (05-06) Allocation Release Expenditure Expenditure/ Release

Rs. 257.50 Crores Rs. 169.72 Crores Rs. 48.14 Crores 28%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/ OBSERVATIONS GOVERNANCE Proposals for SPMU/DPMU included in NRHM PIP 2006-07 SUGGESTED ACTIONS Urgently place and train SPMU/DPMU staff

Expedite signing of MOU FINANCIAL MANAGEMENT TECHNICAL INTERVENTIONS 2012 ANMs, 497 Staff Nurses, 92 LTs & 75 LMOs working under contract Recruitment of ISM lady doctors ISM doctors should not be allowed to and GNM completed in 5 districts conduct institutional delivery until they have undergone SBA training. Funds released for 9878 RCH camps. Camps being conducted regularly 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 to districts for incentive payment of Rs. 100 per sterilisation case to AWW Sensitise AWW for RTI/STI so that they can refer such cases ASHAs to get compensation on time

- 173 -

ACHIEVEMENTS/ OBSERVATIONS

SUGGESTED ACTIONS Promote and monitor monthly village health days Activate ANMTCs. There should be one functional ANMTC per district. State to build a nursing cadre.

TRAINING/ IEC/ NGO INVOLVEMENT Meetings conducted regularly at panchayat level at more than 80% sites Annual training plan finalised

ANMs, ASHAs, PRI members to be sensitised on RCH II / NRHM through sector meetings

INNOVATIONS Solar panels in PHCs and FRUs to Adequate focus required on address acute shortage of power in the maintainance. state Plan to have 2 ANMs per SHC All ANMs to be connected to a functional health unit. Problem of most ANMs staying in urban areas on deputation, etc. to be addressed.

State has repositioned IUCD as Suvidha. HLL doing social marketing for this. M&E AND TA REQUIREMENTS

Government could provide scooter loan to ANMs Effectively utilise Divisional Commissioners for strengthening of HMIS. Front line supervision to be strengthened through mobilising LHVs.

OTHER ISSUES GOI to send Infection Prevention & Waste Disposal guidelines/ UPHSDP guidelines if available to be used.

- 174 -

Progress on 13 identified indicators ( as provided by the state) Sr. RCH INDICATOR Level of achievement No. 1 % of ANM positions filled ANM Sanction working Regular 23656 23576 Contractual 2500 2012 Total 26156 25584 25584x 100/ 26156 = 97% 2 a. % of districts having full-time programme manager for RCH b. Administrative and financial powers delegated

vacant 84 488 572

Dy CMO RCH has been appointed Nodal Officer for which circular has been sent. 70x 100/ 70= 100% Dy CMOs do not have full time responsibility in most districts

% of sampled state and district All Program officers are being oriented from program managers aware of their time to time, 7 workshops organised in this responsibilities regard 70/70 x 100 = 100% % of sampled state and district 100% programme managers whose performance was reviewed during the past six months % of district not having at least one Information is being received from all districts month stock of as soon as is available will be provided. j. Measles Vaccine k. OCP l. Gloves in the past six months? % of districts reporting quarterly Date fixed to first quarterly report from districts financial performance in time 10th of July 2006, districts reported 35 day delays. 16/70x 100 = 23% 50% received until September 15. % of district plans with specific 0% activities to reach vulnerable communities % of sampled outreach sessions Guidelines not seen during field visits. where guidelines for AD syringe use No date available for safe disposal of AD. and safe disposal followed % of sampled FRUs following 0% as per filed visits observations agreed IP and health care waste disposal procedures % of 24 hrs PHCs conducting 130/232*100=56% minimum of 10 deliveries per month % of CHCs upgraded as FRUs 34/50 reported to be operationalized. offering 24 hr EmOC services Observations during field visits indicate most of these not fully functional. % of sampled health facilities 50/70 x 100 = 71.42 offering RTI/STI services as per the agreed protocols M&E Triangulation

7 8 9

10 11 12 13

- 175 -

RCH II: FINDINGS OF 2ND JRM WEST BENGAL West Bengal has taken a number of key governance related steps (including creation of a separate health management cadre) and systematically formulated various strategies. There is now a need to step up implementation and achieve ground level impact. The immunisation rate of 54% (DLHS) is not acceptable. Financial progress Allocation (05-07) Release (1/4/05 to 30/6/06) Expenditure (1/4/05 to 30/6/06) Expenditure/ Release Rs. 191.00 Crores Rs. 90.05 Crores Rs. 8.59 Crores 9%

Component wise observations and suggested action points are as follows: ACHIEVEMENTS/OBSERVATIONS GOVERNANCE Separate Drug Corporation being established to streamline drug, equipment and inventory management Separate cadre of West Bengal Public Health Administrative Service created out of West Bengal Health Services. FINANCIAL MANAGEMENT Introduction of Internal Audit through Chartered Accountant Firm in all facilities upto Sub-district hospitals. Constitution of Audit Committee at the State level Medium Term Expenditure Framework (MTEF) completed. Review of procurement system completed recommendations under consideration for implementation. Design for Health Insurance Scheme under process. TECHNICAL INTERVENTIONS Support being rendered from RCH II for IEC should be awareness generation and sensitization among strengthened to provide more different stakeholders information on RTI/STI Try to look into the issue of early marriage at Panchayat level Diagnostic kits being given to DH/SDH for RTI and STI interventions RTI/STD diagnosis in collaboration with WBSAPCS should start from village level INNOVATION Initiatives have been taken jointly with Department of Panchayat & Rural Development for organising monthly meetings of AWWs / ANMs / GP Pradhans and other elected officials, launching of Community Health Care Management Initiative (CHCMI), and Construction of Sub-Centres and Primary Health Centres from other sources. SUGGESTED ACTIONS

- 176 -

ACHIEVEMENTS/OBSERVATIONS EQUITY AND ACCESS The ranking of all blocks with reference to RCH indicators and disease load has been analyzed and ranking exercise completed in consultation with PRIs. Blocks with poor ranks have been identified for special attention. Frontline Honorary Health Worker (ASHA) being engaged in 74 most backward blocks predominant among them are SC/ST Blocks. Engagement of Second ANMs is also being prioritized in the backward blocks as per the ranking done. M&E AND TA REQUIREMENT

SUGGESTED ACTIONS

ASHA for NRHM has been approved for 5 blocks rest of ASHA may be put under RCH II as health workers

State to systematically provide documentary evidence for achievement of core 13 indicators as specified in Enclosure 4 of the JRM Process Manual. OTHER ISSUES All Block Primary Health Centres (CHCs) being upgraded to 30-bedded Rural Hospitals May partner with The Red Cross for the requirement of blood banks.

- 177 -

ANNEX 7 MOHFW PROGRAMME DIVISION REPORTS

MOHFW PROGRAMME DIVISION REPORTS Donor Coordination Division / Programme Management ACHIEVEMENTS/ OBSERVATIONS Memoranda of Understanding with the MOHFW for implementation of the RCH II program state PIP have been signed by all States except Karnataka, UP, Delhi, Lakshadweep, and Andaman & Nicobar. GoI has approved the establishment of NHSRC as an autonomous society. Appraisal of PIPs completed. PMU induction training under way. SUGGESTED ACTIONS Follow up with the remaining 4 states /UTs

Ensure that legal formalities are completed and ED appointed

PMU Help line was established. Created an ehelp desk. (infonhsrc@gmail.com)

Procurement Division Good progress in implementation of several agreed actions to improve procurement arrangements despite some initial delays. ACHIEVEMENTS/ OBSERVATIONS Empowered Procurement Wing (EPW) established; procurement activities of both health and family welfare wings brought under EPW; single Integrated Purchase Committee under DGHS SUGGESTED ACTIONS A timeline to be developed for procurement manual, bidding documents, etc. Harmonize procedures across different programs. EPW to look at procurement guidelines and send to states to incorporate in the upcoming PIPs. Need for evolving a business plan for the EPW clearly defining its status (registered society/MOHFW department) and scope of work (procurement/oversight) for RCH, recently approved Tuberculosis II and pipeline projects especially HIV/AIDs and Vector Borne Diseases Control. Support to be provided for strengthening State procurement systems. TNMSC model may be followed.

Procurement Plan 2006-07 for RCH-II prepared and put on website of the Ministry Procurement of drugs under RCH decentralized to States during 2005-06 Compendium of technical specifications for 800 equipments covering 42 specialties prepared

- 177 -

ACHIEVEMENTS/ OBSERVATIONS Guidelines for procurement of drugs under NRHM and RCH programmes prepared and sent to States Pending appointment of a procurement agent, urgent procurement to be carried out by EPW under supervision of Crown Agents Crown Agents after review of existing procurement organization, resources, practices and procurement system of the MOHFW to identify the areas that need further strengthening has submitted Inception Report List of over 600 manufacturers with valid WHO GMP certificates put on website MOHFW has shared the draft TOR for quality and quantity survey, which is currently being reviewed by the development partners. Finance Division / FMG ACHIEVEMENTS/ OBSERVATIONS System for electronic transfer of funds from Centre to States introduced Provisional UCs for FY 2005-06 received from all 35 States/UTs Organized training for finance staff at States and districts, developed accounting guidelines for districts and sub districts and placed all financial information (fund release, utilization, finance manual) on the web site of MOHFW Delays in delegation of financial powers

SUGGESTED ACTIONS

SUGGESTED ACTIONS

Designed an accounting system in Tally and would be demonstrated in some states. Audit reports for FY 2005-06 have been received from only 9 States and the rest are expected by November 2006. FMG has carried out management audit in 8 States

CDMO may sign the cheque once budgetary approval from DM/DC is received ( as agreed at the Goa conference). Need to improve the quality, correctness and timeliness of the FMRs and emphasize reporting in the formats provided in the FM Manual. It is also important to monitor the expenditure reported by the States against approved PIP.

M&E Division

- 178 -

ACHIEVEMENTS/ OBSERVATIONS MIES format developed and sent to states. Reports slowly coming in. Fieldwork for NFHS 3 complete. Data released for 5 states. Other results to be out soon. DLHS-3 modified to include Facility Survey. Fieldwork to take one year and entire state to be covered in one phase. Equity indicators incorporated in survey design of NFHS, DLHS. Preparatory work for Quality Assurance surveys completed. To be done in UP, UA, WB, MH, KA and AS. Programme Management study in Gujarat completed by IIM-A. (Rajasthan study incomplete). Pilot to be done in 5 states. No progress on Community Monitoring systems for Triangulation of Data.

SUGGESTED ACTIONS Closely follow up with states. Delay in NFHS-3 data processing. IIPS capabilities for data processing a concern. Registrar General of India being considered for DLHS-3.

IEC Division (IEC/BCC and ARSH) ACHIEVEMENTS/ OBSERVATIONS ARSH Implementation Guide prepared and disseminated. Training packages developed for programme managers, MOs, and LHVs/ANMs and shared with states. National BCC Strategy finalised. Intra communication being developed. National BCC Resource Centre established. Several initiatives taken for intensified branding of RCH/NRHM. SUGGESTED ACTIONS

Support the States in implementing a decentralised BCC Strategy. BCC Resource centre recruitment to be fast tracked. Overall awareness of RCH/NRHM is still low.

Maternal Health Division Overall good progress in development and dissemination of various guidelines. Need to monitor and support implementation. ACHIEVEMENTS/ OBSERVATIONS Developed technical guidelines for Skilled Birth Attendance, management of common obstetric complications, 24 hours service provision through PHCs, operationalisation of FRUs, and training in emergency anaesthesia skills, and disseminated to States. SUGGESTED ACTIONS Clarify guidelines, especially for operationalisation of facilities (full complement of essential services not always being provided) and SBA (because of

- 179 -

ACHIEVEMENTS/ OBSERVATIONS Guidelines for safe abortion at primary health care facilities using MVA finalised and disseminated.

SUGGESTED ACTIONS some confusion in States between SBA and TBA).

Draft Policy and Operational guidelines for IMEP in SCs, PHCs, and FRU have been developed. Guidelines for RTI/STI services not yet finalised. JSY scheme amplified to increase accessibility to the poor in 10 low performing states. Awareness of JSY still poor.

IMEP guidelines a good step. Speed up finalisation. Finalise RTI/STI guidelines. Develop strategies with IEC division for increasing awareness. Use PRIs, community groups, etc.

Child Health Division Overall slow pace of progress in finalisation of various guidelines and policies. ACHIEVEMENTS/ OBSERVATIONS The IMNCI Guidelines finalized and disseminated. 75 districts identified for implementation, out of which 33 districts are already at an advanced stage of implementation. More than 14,000 workers including Anganwadi Workers (75%) and health staff (25%) have been trained in these districts. The Department of Women and Child has made a policy decision to include IMNCI training mandatory for all Anganwadi Workers (AWW). There are no intervention for newborn care and management of sick children in non-IMNCI areas. The implementation pace of IMNCI is constrained by the limited pool of state level facilitators and technical assistance available at district level. There are enough national trainers, but they have limited mobility to the States. Training material and training strategy for home based newborn care is being finalized. A committee has been formed to review and recommend use of antibiotics by ANMs (Inj. Gentamycin), and trained community based workers (co-trimoxazole) such as AWW, ASHA and link workers. Several other child health policies are in different stages of development (e.g. Zinc in diarrhoea management, Iron syrup in under-2 children) Alternate vaccine delivery systems and immunization weeks to improve coverage in difficult areas. Measles surveillance guidelines developed and disseminated.
- 180 -

SUGGESTED ACTIONS Increase training institutions for IMNCI.

Clearly define role of ASHA and ANM in mobilising and delivering child health services. Referral mechanisms for sick newborns and children need to be developed (some states already have initiatives).

ACHIEVEMENTS/ OBSERVATIONS No vaccine stock-out of more than 1 month reported. Full requirement of AD syringes supplied. Hub cutters supplied to few states. Funds for constructing safety pits at PHCs has also been released. RSS Division / Family Planning ACHIEVEMENTS/ OBSERVATIONS Increasing access to CuT 380A through a pilot project on Social Marketing/ Social Franchising in CuT 380 in 3 states- Rajasthan, Gujarat, Bihar; constitution of Expert committee on Training in IUD (skill training) and IEC for scaling up CuT380; and Contraceptive Update training for public and private doctors. Increasing awareness of Emergency Contraception through various mechanisms. Various mechanisms for increasing availability of NSV services (training of service providers, camps, increased compensation, increased awareness). Standards on Sterilisation updated and SOP for Sterilisation camps being developed. Quality Assurance Manual developed. Quality Assurance committees set up at State and district levels. Slow progress on Family Planning Insurance Scheme.

SUGGESTED ACTIONS

SUGGESTED ACTIONS Develop plan for increasing awareness of spacing methods among service providers (lack of awareness on benefits of different spacing methods). Study feasibility of providing EC pills in ASHA kits to increase availability of ECs. Increase no. of training institutions for NSV to achieve target of one NSV trainer per district.

Training Division Considerable progress in Training since last JRM. Overall training management at national level is now better streamlined. ACHIEVEMENTS/ OBSERVATIONS Operational guidelines for conducting trainings under RCH developed and disseminated. 33 states have developed CTPs. Guidelines for selection, training and compensation of ASHA as well as guidelines for setting up the support system have been developed and circulated to the States. 4 training modules for ASHA developed and disseminated. SUGGESTED ACTIONS District needs should be incorporated in CTPs. CTPs to be linked to HR Plan and rationalisation of facilities.

- 181 -

ACHIEVEMENTS/ OBSERVATIONS NIHFW has been given in principle approval as nodal institute for the training under NRHM/RCH-II, with support of 20 Collaborating Training Institutes (CTIs) till 2010. NGO Division ACHIEVEMENTS/ OBSERVATIONS 404 districts covered by 297 MNGOs. MNGOs have submitted 146 composite district proposals. Implementation started in 91 Some states such as Orissa, West Bengal, and Jharkhand are using MNGOs for ASHA training. Lack of Awareness about the Scheme amongst District and State officials Enormous delay in Field appraisal by DMs/DCs

SUGGESTED ACTIONS

SUGGESTED ACTIONS Concern on performance accountability of MNGOs. MoUs and project proposals need to have performance measures in place.

- 182 -