Just Passed - NRHM!

8/3/2019 Just Passed - NRHM!

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JUST PASSED!

On Performance of NRHM

SUGGESTIONS TO THE WORKING GROUP FOR THE 12TH FIVE YEAR PLAN

Here, we have considered the Discussion paper as a reference document. Our

comments and suggestions are mentioned under each sub topic as per the

Discussion paper.1

A. Outcomes in Maternal Mortality:

India will be short of MMR Goal of 100

Our comments:

There is a significant decline in maternal mortality in India during the NRHM

2007-10 period, as the data shows, all the limitations notwithstanding.

However, the discussion paper points out the shortfalls in EAG states and

within the southern and other Non EAG ones eg Karnataka and Haryana,

slowing down of MMR decline in Maharashtra, weak correlation between

MM ratio and rates in EAG states are some of the key concerns. All thesetrends indicate that the specific regions and communities in every state may

have specific problems social behaviour, infrastructure including roads,

transportation systems etc.

Main causes of better performances at southern states seem to be

systematically operationalizing forward and backward linkages for safe,

institutional deliveries: incentivizing motivation for institutional deliveries,

EMRI from home to hospital and back home, (Assam, HP, AP, Gujarat, some

NE states) making 24x7 SDH level facilities, improved availability of

medicines, (TN, Manipur) special tribal health care management units (in AP).

Our suggestions

1After each set of suggestions, there is a score out of 10 for the achievement. The rest ofcomments and suggestions are based on the comments circulated by Renu Khanna and Sunil Kaul,

the scoring is entirely by me based on Shyam Ashtekars model. So please send me your comment

on the score, its system and its subjectivity. Dhruv Mankad


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It is therefore suggested that in order to find out gaps in other states, detailed

operational reviews are essential. Except ASHA and to some extent the JSY

programme, none of the other programmes are evaluated in details.

Comparison between MMR as maternal mortality ratio and the maternal

mortality rate.

Our comments:

According to the paper, the reduction in total number of maternal deaths,

lower fertility rates by themselves bring about. Statistically, this may be a

correct interpretation; its relevance to the residual population needs to be

examined. However, the correlation of these two indicators is weak in EAG

states as compared to other regions. (Figure 1) It also mis-indicates that birth

control alone sans controlling any other factors in mothers having low

education status, low decision making role, early marriage, low nutritional

status particularly IDA, low, post natal care, low spacing etc will indeed

reduce the mortality rates! This is particularly true when reducing maternal

morbidity through better postnatal care is still not on agenda.

Our suggestions

Therefore we suggest that emphasis on target free approach for family

planning must be encouraged. Otherwise it may lead to reversal of the

laudable paradigm shift that NRHM has brought in - from family planning to

convergent primary health care. It is clear from the success of strategy of

institutional delivery that improving supply side management will create moredemand and improve its outcome. The same logic should follow in case of

fertility control.

Let us accept that this achievement is despite lack of several components

of an adequate EmOC services and not because of it. The slowing down in

non EAG states is a warning signal.

Our score for reaching this achievement of this goal is 6.


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Figure 1: Comparison of drop in Maternal Mortality Ratio and Rate in states

(2004-06 and 2007-09)

B. Outcomes in Infant and Under 5 mortality:

Our comments:

The national infant mortality rate has declined both in rural and urban areas during

the NRHM. However, at the existing falls, we would well short of the goal.

The decline in under 5 mortality was similar. However, the NRHM has had low

impact on decline of U5MR in rural area and among girl children.

The variations in decline in IMR and U5MR along with rural and gender

differences also indicates that certainly these variations reflect within the states.


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There is a close correlation between state wise drops in maternal mortality ratios

and IMR. Apart from the factors which affect the MMR, other factors like

improved neonatal care, breastfeeding and weaning practices, spacing,

supplementary feeding, economic status of the family and the region etc. also

affect largely the IMR.

Our suggestions

Therefore we suggest detailed operational reviews between and within states

should be carried out to identify gaps in implementing relevant programmes.

Supplementary feeding programmes have been evaluated in the past including

ICDS, Mid-day meal, PDS etc.. However, the role of these programmes in

relations with overall food security at family level and its contribution in reduction

of malnutrition requires to be carried out.

Our score for reaching this achievement of this goal is4.

C. Progress on Population Stabilization:

Our comments:

The Census 2011 (that) the demographic history of the country, as it is

perhaps for the first time, there is a significant fall in growth rate of population

in the EAG states after years of stagnation.

The fact that existing interventions to reduce maternal and child mortality

rates along with availability of family planning services have had an impact

across all the states.

Our suggestions

In fact this achievements during the NRHM underlines that these interventions

to reduce maternal and child mortality rates must be strengthened in quantity

and quality to ensure that gaps in population stabilization would be filled up.

Our suggestion that the paradigm shift that NRHM has brought in must be

maintained, is vindicated.


D. Outcomes of Clean drinking water for all:


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Our comments:

Figure 2 shows the achievements of this goal. There are still 30% of locations

having adequate coverage for drinking water. However, the continuous back-slipsis a major concern.

Also the data does not give us any information about time of drinking water

availability, distance of its source and its quality.

Our suggestions:

Detailed study about time period of drinking water availability, distance of its

source and its quality is required. Its impact on maternal morbidity also needs to

be explored.

Intersectoral Convergence should emphasize on involvement of DW authorities.


E. Reducing malnutrition among children of age group 0 to 3 to half its

present level and reducing anemia by 50%

Our comments:


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Although there are no figures available after the NFHS III, there are indicative

studies conducted in various pockets of vulnerable remote areas, in various states

that probable causes of malnutrition: mothers nutritional status, immunization,

drinking water, mothers education, breast feeding practices, ICDS serving 0-2

age group of children still remain to be achieved.

ICDS has been dropped out of inter sectoral convergence as all the PIPs show.

This has been recognized as one of the causes of malnutrition in India.

Our suggestions:

Concurrent evaluation of all nutrition interventions should be made public.


F.Raising the sex ratio for age group 0 to 6 to 935 by 2011-12 and 950 by 2016-17

Our comments:

According to your note, the child sex ratio in India has dropped to 914 females against

1,000 males - the lowest since Independence. According to 2011 Census, the child sex

ratio has declined from 927 females against 1,000 males in 2001 to 914 in 2011.

Our suggestions:

First, our suggestion is rigorous enforcement of PCPNDT Act on use of sonography.

Second is to involve State Medical Councils, FOGSCI, Radiological Association and

other Medical Association to bring about professional pressure on colleagues

performing acts which encourages sex selection. Enforce MCI and state councils to

carry out their duties to ensure that the licensed practitioners practice according to the

legal and ethical boundries.

Final suggestion is to encourage behaviour and positive discrimination for girls andtheir parents eg a pension scheme equivalent to a retired government employee for

one of the parents particularly the mother of two daughters.

Our score for reaching this achievement of this goal is -5.

G. Increase in public health expenditure

Our comments:

Although, the public health expenditure has gone up due to the mission, it has reached

nowhere near projected level.


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It has not increased upto the proportion of GDP as public health expenditure (0.9 in

2005-06 to 1 in 2011-12). It has not increased substantially as a proportion of state

budget.

The absorbability of funds from state departments, State society down to the VLHC is

variable. As per all CRMs, the public health services managed largely not being

impartial and professional approaches and politically neutral area are the mainproblems, making this mission functional.

Our suggestions:

Create a National Health Fund where unspent fund remains so that the fiscal

commitment is actual and not notional.

Use additional funds for HR development and for hospital centred services.

The absorbability of funds from state departments, State society down to the VLHC

should be increased by introducing efficient mission management, monitoring and

internal auditing system at state, district and block level Make State health department and health societies down to VLHC trained with proper

accounting and internal auditing system so that men would not be the receivers of

JSY incentives!

Make Tamil Nadu model of drug procurement and distribution become mandatory

with provision for innovative alternatives like the Rajasthan models.


.

H. Increase in healthcare infrastructure, human resources and provision of

health services, specifically to women, children and the rural population of the

country

Our comments:

Although there is an increase in the health care infrastructure and in human resources,

it is mainly on a haphazard, arbitrary and knee jerk mode.

Choice of location for PHC, SC is not on the basis of accessibility criteria.

Several states have different models under the Referral Transportation Programmes.

States like AP, Gujarat, Assam, HP etc. have shown successes. However, there are

very few systems which are evaluated concurrently. Maharashtra though the report

says, have a referral transportation system, it is actually only a vehicle made available.

It is not equipped with any capacity to handle any emergency except bringing the

patient to a referral unit from a health station. It does not provide home to hospital

services. There are experiences where BPL patients have paid diesel and chai pani

charges!

There is no overall HR policy as such; contractual appointments have become the

rules rather than as supportive policy: that too is with a collective slavery mode buy

cheap labour. This in addition to rampant selling of posts ensures non-performance

and impossible HR management. There is no induction policy, reward punishment

modes, non-accountability etc.

There is often no congruency in infrastructure and human resources on one hand withthe health care needs due to the location, community it covers, epidemiological


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evidence. Eg PHCs on highway handle cases of road accidents; PHC closer to forest

areas receive cases of wild animal bites, insect bites etc. Even, institutional deliveries

are carried out where there is no institutional or personal competency for BEmOC/

EmOC. Specialists are recruited for MCH programme but there is little use of their

expertise for illnesses other than LSCS and new born care. Counselling and

physiotherapy are not part of a hospital team at CHC level. ASHA is considered as amedical appendage or a helper of the MPWs. Monthly meetings are often conducted

by Lab Technicians! Their payment is inadequate and irregular.

There is no congruency between trained staff and their placement eg BEmOC trained

staff posted at SC which is not a 24x7 SC or EmOC trained medical officer posted at

PHC with no other staff are trained.

The quality of training is far below than required: it is theoretical rather than skill

based, non-participatory. There is no backup system for staff undergoing training.

There are no evaluation studies of the impact of staff retention policies.

Our suggestions:

Overhaul the HR policies and practices following some good practices in other

departments like the Railways, Armed Forces Medical Services, Department of

Forest, Education etc.

Create a cadre of IPHS. Include family needs e.g. child education, family stations v/s

non family stations.

Enforce rules diligently. MO on duty not present at the premise is equal to

absenteeism enforce it.

Tasks of experts necessary at RH/FRU/CHC level should be beyond MCH

programme. Managing a center of this size should be like a medium size hospital withadequate equipment, medicines and facilities essential for the purpose. These facilities

can also help staff retention.

Professionalize the training institutes from district upward level. Environment, posts

(in one institute in Maharashtra a statistician was doing most task as a senior clerk!

This is true even of a counsellor working as a MIS maintainer. !!). Training institutes

must have an HR management work environment with all statutory requirements of

an educational institute. Eg, ethical committee and Vishakha Committee.

Referral Transportation System should go beyond availability of vehicle. A proper

protocol should be ensured and a separate referral transportation system on the line of

a fire station needs to be designed and supported. Products made out of Half-hearted

efforts are often burdens rather than assets.

ASHA payment should be adequate matching the minimum wages act as skilled and

health workers, regular and with convenient approaches like cash vouchers

reimbursable at any nearby bank.

Our score for reaching this achievement of this goal for infrastructure is7and

for HR it is4.

I. Improvements in programme management capabilities:

Our comments:


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There are changes in the district and block level health management structure.

However, often it does not match overall HR, infrastructure and load it needs to be

designed specifically to the needs of every district/block level.

The role of BHO is mainly firefighting one and as an extension of DHO.

DPMU is the only unit created under the NRHM.

RKS have been created under NRHM as a management support unit from districtdownward level. But it mainly consists of government staff who is already

emburdened. It has not served the purpose of including civil society.

Our suggestions:

Additional staff should be allowed at DMPU as per their needs.

Visiting at least two ASHA meetings as AP norms should be part of DPMUs task.

DPMU should be at the premise of DHS.

A separate office with a team of technical and administrative staff should be

considered. RKS was envisaged as a partnership between government and civil society. It has

become more like yet another government committee. A separate office and specific

tasks on the Silvassa model should be encouraged with an independent managers

post.


J. Strengthening community processes and community ownership of public health

services: and changes in flexible funding.

Our comments:

Experience from several states indicates that the VHSCs are still being

constituted without going through the due process. Members of VHSCs are many

times not aware that they are indeed members! Elsewhere the VHSC is constituted

with AWWs, Pada workers, ANMs and ASHA thus defeating the purpose of

community process.

The Community participation is not considered as a managerial advantage because of

the holier than thou feelings. In fact, such resistance it results in more problems and

conflicts between the patients and the provider.

Community is not aware of the services available at which level.

There is no communication centre at any place where the community can accessservices whereby particularly women get counselling and information. Often, news

and reports about these are only on paper.

ASHA programme is considered in reality as an escort particularly for pregnant

women. ASHA is not considered a social activist interfacing between the public

health system and the community. She is considered as an extension of the public

health hierarchy. She is not a primary caregiver, often there is no kit distribution or

replenishment process. There is no hand holding processes in the field by the health

professionals. ASHA payment is simply meagre and not in consonance with the legal

bindings under minimum wages act, Provident Fund act, contract labour act and now

domestic workers act. She is NOT a volunteer. This concept is not tenable at all. She

had applied and recruited as a part time worker providing services to the community.


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Community based Monitoring and Planning is an innovative programme where the

community can participate in assessing the primary health care services and its

quality. It has been piloted in 9 states and has promising results in improvement of

availability and accessibility of health care. It has also created a platform where the

grievances are aired and often quick actions are taken. It has also improved the

administrative pitfalls like absenteeism and misbehaviours among staff, or lack ofsecurity to them etc.

Our suggestions:

Community participation processes and their ground realities need to be monitored

more stringently, so that the process laid out is followed and the structures created

become functional.

Health systems personnel need to be sensitised about the benefits of promoting real

community participation many providers are still threatened by active

communities who help as well as challenge.

Effective grievance redressal systems need to be implemented so that peoples

confidence in health systems is increased. Some concrete action to improve grievance

redressal would be to develop, through a participatory and transparent process, a

facility-based or regional system of ombudsmen to receive grievances and pursue

timely redress. This mechanism should be easily accessible to women with little or no

formal education.

Further, early response systems should be developed, including a telephone hotline

for health-related emergencies for women facing especially obstetric emergencies.

Guaranteed health services should be displayed in all health facilities, thus enabling

people to demand these services. This should be accompanied by display of phone

numbers of officials to be contacted in case of grievance, and the grievance redressalmechanism in simple language. Various types of information related to the

performance of health services, maternal and child deaths, usage of RKS / IPHS /

Untied funds at various levels should be displayed and updated on a regular basis in

respective facilities (as per mandatory display under the RTI act mentioned in

IPHS). All such information should be made available to ordinary citizens and civil

society members on request.

Public dissemination of the analysis of HMIS data that is collated both at district and

state level, along with systemic actions taken based on these findings, should be done

to increase transparency. In addition, flow of HMIS data downwards would improve

local ownership of data. Data collected and action taken at every facility could be

proactively disclosed in culturally appropriate formats to local communities, alongwith local participation in decision making.

In all the EAG states and in vulnerable pockets of non EAG states, the focus should

be to provide the ASHA with the skills and support to strengthen her ability to

provide home based new born care and care for the child. In the non EAG, where

programmes for non communicable diseases, mental health, palliative care, eye care,

adolescent health, gender based violence, disability, etc, can be piloted, ASHA should

be trained in counseling for behaviour change, basic screening, referral and home

based primary care.

A complete independent managerial structure for ASHA like the SEWA bank modelof empowering them as professional women volunteers can be considered.


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The CBM and P should be scaled up and incorporated under the tasks of VLHCs with

necessary legal amendments. The NGOs role should be limited as a trainer and as a

watchdog with concurrent monitoring mechanism of CBM in this process to assure

that the VLHC remains an impartial process.


K. Improved delivery of Reproductive and Child Health and Nutrition

services.

Our comments:

Complete absence of a professional approach in most of the public health services by

most of the staff. Denials of health care services, provisions of JSY if not from the same

state (despite SCs judgement), asking for money even before admitting a 3 rd parity

mother, asking for money by ambulance driver before referring at risk mother, delay inCS, the list is long. Technically speaking, not following any patient management

protocol but emphasising on administrative procedures.

Referral transport system is not uniformly run. Patient not accompanied by nurse,

leaving to the family to decide with no counselling, no linkage to POL budget and use

of transport vehicles, intrusion of private taxi owners in this business with probably

double charges due to meagre referral charges paid to private taxi owner (Rs 250 as a

flat payment with no relationship with distance and time travelled, in Maharashtra in

contrast with Rs 1000 per day payment in Janani Express scheme in MP)

Institutional delivery has an element of equality and not equity! What is the definition

of ID? If at risk, then it should be at an institution which is competent to tackle the

emergency! And in India almost all pregnant mothers are at risk when considered at

least one the indicator BMI, Hb level, age or parity, etc.

There is no HMIS analysis of MMU. How many patients they are serving, are they

really looking at the children and pregnant mothers? (One small study of a CSR

intervention, it showed that considering the time the clinic is visiting, most of the

patients were elderly women. Lets consider it as a geriatric intervention not equipped

with medicines, instruments, competency to deal with a geriatric OPD.!)

JSY is an incentive which has made the IDs possible and ASHA to be accredited!

However, there is a clear lack of awareness among who really need it. Urban

beneficiaries are swindled than because there is no monitoring system as it exists for

rural health services. Finally, the post natal care services have not improved and there is no mechanism yet

devised for this problem.

Our Suggestions

Staff at all levels, need to undergo sensitisation programmes about responding to

patients needs and observing patient rights, behaving respectfully with patients,

especially adivasi patients including women, and use of common health related terms

in local adivasi language. Sensitisation and Reflection Workshops need to be

conducted as part of an Organisational Development effort. These could address

issues like professional ethics, commitment to duty, sensitivity to the concerns of the


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poor, tribals and women, power relations, Indian Constitution, human rights, and

respect for all individuals.

Equipping Health Facilities and Providing Services. In several states there is still no

rationality in preparing institutions to provide to provide Comprehensive and

Emergency Obstetric Care. Make select facilities fully functional as CEmONC and

BEmONC Centres particularly in the underserved areas. Ensure that CHC/ FRU havestaff, facilities and infrastructure for c-sections, emergency care, and provision of

skilled personnel, equipment and supplies, particularly in underserved areas. Fill

upvacancies of doctors and other related staff as soon as possible. Undertake efforts to

ensure that the District Hospitals are equipped and staffed adequately to discharge

their functions of dealing with critical case load. This will also include efforts to

improve the motivation and morale of the work force. If patients are not accompanied

by suitable donors, blood must be made available to them from the blood bank. If

fresh blood is required or the bank does not have the required group, personnel at the

blood bank should contact suitable donors from a regularly updated donor list that

should be available at the blood bank at all times. Patients in critical need of blood

should also be given blood free of cost if they are not in a position to pay. Ensureprovision and monitoring of safe abortion services in CHCs and PHCs.

Human Resources: Post individuals in weaker districts who are known for their result

orientation, efficiency and integrity, and give them all the support that they need to

turn the situation around in these districts. Deploy available human resources

rationally and ensure through creating an enabling environment that they can

contribute effectively. Develop creative solutions for managing the human resource

shortage, without compromising the quality of care; examples of good practices from

various states will be useful. Undertake urgent skill building, training of all staff

engaged in delivering services, and set up monitoring mechanisms to ensure

supportive supervision post training. Develop a realistic plan to strengthen theprimary health care in tribal districts, including:

Strengthening and monitoring of required numbers of ASHAs.

Strengthening ANMs with SBA training and ensuring that subcentres can handle

quality ANC and normal deliveries. Improve the infrastructure of the subcentres to

ensure that the ANMs can stay and provide quality ANC, Intranatal Care and

Postnatal Care.

Identifying skilled Dais, and building their capacities to handle normal deliveries and

identify complications especially in difficult areas. Ensuring support for Dais,

including access to Emergency Obstetric Care when required. There should also be abetter system of remuneration and incentives/ rewards for Dais.

The cadre of Male Multipurpose Workers needs to be strengthened to address male

sexual health needs. This can be a point of converging the NACP and RCH. And this

will also address Adolescent Boys concerns related to sexuality.

Ensuring Quality of Care. Ensure continuity of care through the antenatal and

postnatal periods, with follow up care in case of complications. Ensure that a regular

schedule for VHNDs is planned, publicly disseminated and implemented. Provide

adequate support to health care staff for travel towards this. Set up monitoring

mechanisms to ensure delivery of a select package of services, including appropriate

antenatal care, nutritional interventions and immunisation.


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Monitor malnutrition closely so as to prevent acute malnutrition, and provide special

nutritional support for malnourished children and women.

Develop systems to make referrals accountable, including provision of ambulances,

and continuity of care during referrals by providing accompanied transfers.

Referrals to a higher centre must automatically include provision of ambulance.

Referrals should be accompanied by the proper referral slip clearly indicatinginvestigation carried out and treatment given, vitals, etc., as well as reason for referral.

Improving Quality through Monitoring. Plan for clinical audits in the District Hospital

and CEmONC and BEmONC Centres. Ensure Maternal Death Reviews take place in

all districts according to National Guidelines including

o Set up and operationalise systems for reporting of maternal deaths both at the

facility and community level.

o Ensure that Maternal Death Reviews are carried out at the facility and

community levels and systemic corrections made based on their findings.

o Ensure that Maternal Death Reviews are institutionalised at the district level in

the monthly Inter Departmental meetings chaired by the District Collector andsystemic actions taken.

District level Maternal Death Reviews are collated at state level and analysed to

initiate systemic changes based on their learnings.

Undertake quarterly reviews against select indicators like maternal deaths, newborn

deaths, referral rates, C-section rates, etc.

Ensure availability of referral transport for problems during post natal care


L. Involvement of private sector and strengthening Public PrivatePartnerships.

Our comments:

The key concerns about private sector involved in public health care services are:

non focused and contradiction in a PPP is it strengthening the public health

services or replacing it, supervision and its regulation right from state to grassroot

level, documenting the innovativeness and its sustainability. Very enthusiastic

committed intervention without adequate human, physical and financialinfrastructure can result in disaster costing the public exchequer.

Purpose of a PPP is a. innovative approach b. model building even of good

governance c. for gap filling of services d. implementing for which the public

health services does not have any track record eg social health insurance. The

second key concern is PPP becoming a way of outsourcing or shirking the state

responsibilities

The third major key concern is the legal, ethical bindings of PPP particularly in

areas of clinical and public health research: are there any detailed guidelines for aPPP in various components of health care, are there any legal documents


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equivalent to the contracting out construction work etc.? Which are the regulatory

authorities with what jurisdictions, levels of competency in framing, supervising

and enforcing such agreements, what are the mechanisms in place for accessing

related information?

Our suggestions:

A clear policy document with detailed guidelines for PPP for health care services

and research should be in place.

PPP should be limited to innovative approaches, inaccessible areas, tertiary care

and turnkey models development.


M. Improved performance of the disease control programmes and their

integration with the rest of the health sector.

Our comments:

There is a significant reduction in prevalence of communicable diseases like

malaria, filarial, dengue, leprosy and TB.

There are key concerns about persistence of AIDS, MDR TB, sporadic insurgence

of malaria and dengue, pockets of high prevalence of leprosy (in one tribal PHC

area in Nashik, 71 cases were identified prevalence rate being 4.7/1000 very

high than national rate.)

Introduction of Artemisinin Combination Therapy as a part of managing drug

resistant PF malaria is a major concern. The main reason is that the strategy is not

clinically assessed drug resistence but as a public health measure. This can lead to

treating not actually CR PF malaria with protocol limited to CRPF case because

the sensitivity of RDK in not high. Secondly, this will add to a verticality of all

preventive measures of CDs and thirdly, this is the last resort available for DR

malaria.

Final concern is the consistent verticality of illnesses which require

horizontalization with a patient centred approach.

Our suggestions:


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Introduce a post of general physician at the CHC level, integrating the FRU into

a true secondary care hospital.

Include CSOM, RHDs, adult pneumonia, chronic renal diseases in the list of

preventable communicable diseases

Align all secondary preventive measures (early diagnosis and treatment) of

public health with the clinical case management measures.

Carry out epidemiological studies about high prevalence zones of leprosy

Integrate all CDs and NCDs under a single umbrella


N. Improved access to drugs and diagnostics.

Our comments:

Although, there is regulatory mechanism in place for drug production, price

control mechanism, rational drugs but it is not functioning in the manner itshould be.

Cross practices are rampant and is so OTC sales

Drug researches and sale through medical professionals is common

Irrational treatment both through monetary gains for the care giver and lack of

awareness or a short cut healing for the receiver

Prescribing drugs at public health services

Our suggestions:

TNMSC model should be mandatory for drug procurement, storage and

distribution

No prescription at ALL public health services center for drugs or diagnostics

All essential drugs and diagnostics should be available free of cost

Drug research should be regulated stringently to ensure that it is conducted

ethically, with no loss to the person volunteering as a subject, the volunteer

should be insured.


Here is the NRHM scorecard. It has just passed!


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SCORE CARD

SNo Goals and Objectives

Expected

Achieved

1 Maternal Mortality and RCH services 10 7

2 Child mortality 10 43 Population stabilization 10 7

4 Clean Drinking Water 10 5

5 Malnutrition and Nutrition Services 10 3

6 Sex ratio 10 -5

7 Public Health Expenditure 10 4

8 Human Resources 10 4

9Programme Management Capabilitiesimprovement 10 5

10 Public Health Infrastructure 10 7

11 Public Health Services 10 612 Control of Communicable Diseases 10 6

13 Inter-sectoral Convergence 10 4

14 Community Participation 10 4

15 Drug and diagnostics 10 2

16 Public Private Partnership 10 3

160 66

41%Here is its RADAR! I acknowledge Dr Shyam Ashtekar for usinghis idea of graph design for scoring NRHMs achievement.


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Just Passed - NRHM!