Reproductive and Child Health Programme Phase 2 First Joint Review Mission-777

8/8/2019 Reproductive and Child Health Programme Phase 2 First Joint Review Mission-777

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Reproductive and Child Health Programme-Phase 2

First Joint Review Mission - February 14-March 1, 2006

Aide Memoire

Introduction

1. A Joint Review Mission of the RCH II Programme, led by the MOHFW, was held duringFebruary 14-March 1, 2006. The JRM was joined by the technical, training, infrastructure, urban

and M&E divisions of the MOHFW, as well as by the States. The Development Partners also

participated in the mission on the invitation of the MOHFW. The purpose of the mission was to

review progress in the implementation of the approved State RCH II Programme Implementation

Plans (PIP) as per their work plan and log frame. This review has resulted in an improved

understanding of the strengths and weaknesses in the State Programmes and agreement on actions

to address the gaps, to strengthen Programme implementation and outcome.

2. The mission was organized in three parts; (i) Review of Secondary Data from States:Compilation of data sheets by the States indicating the availability of data on key processindicators, and the States own assessment of their performance; (ii) Field Visits to Identified

States: A team comprising MOHFW and development partners representatives conducted in-

depth visits in three States, (Uttar Pradesh, Chhattisgarh and Assam) drawn from the list of

NRHM high focus States. The team interviewed Programme managers, SPMU and DMPU staff,

service providers and community members; and visited CHCs, PHCs and SCs in two districts of

each State; and (iii) PIP Reviews at National Level: Intensive reviews of the 18 high focus States

and high level review of all States performance by the MOHFW in New Delhi. (Process Manual

for Joint Review of RCH PIPs- Annex- 2). This aide-memoire and annexes summarise the

missions findings and agreements reached made on the implementation of the National and

State Programme Implementation Plans (PIPs), the key policy, management and operational

challenges, and agreed actions to address the identified challenges.

Sector Context

3. The 2nd phase of the Reproductive and Child Health Programme started formally in April2005, although the work on preparing the Programme was initiated in 2003. RCH II is a

comprehensive sector wide flagship Programme envisaging a paradigm shift to promote State

ownership and pro poor focus, improve RCH service delivery for the underserved populations,

and promote district level planning for the sector. The Programme envisages delivery of an

evidence-based package of services along with strengthening institutional capacities to reduce

social and geographical disparities in RCH outcomes. The Programme goals are consistent with

the National Population Policy, the Tenth Five Year Plan and Millennium Development Goals(MDGs). During this preparatory process, the MOHFW conducted extensive consultations with

the States to ensure appropriate understanding of the Programme objectives and focus, and

support the States in the development of their PIPS. The MOHFW has prepared the guidelines to

facilitate the States in the development of their PIPs, based on the findings of a large number of

studies carried out during 2004 on key issues relevant to the RCH agenda. The PIPs were

appraised on the basis of set criteria by a group of experts, and the States were requested to revise

their PIPs based on the feedback of this group. The revised PIPs were then evaluated by all the

http://www.mohfw.nic.in/NRHM/JRM/1st_JRM.pdf


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7. As per the National PIP, the States have started preparing their District Action Plans (e.g.Madhya Pradesh, Chattisgarh, Rajasthan have completed). It was agreed that the district plans

developed for RCH II would form a part of NHRM implementation plans. In addition to the rural

poor, the scope of the plans would also include the urban poor. States are now being motivated to

converging all their health and family welfare Programmes under NRHM. It is expected that this

convergence would be completed by 2007, when the 11th plan will be launched.

8. Since the launch of RCH II, several national level advocacy activities have beenconducted with a high degree of visibility and media coverage, and all the 18 focused States have

launched the NRHM. All States/Uts except Delhi have set up the State Health Missions.

Operational guidelines have been issued to States on Programme management units at State and

district levels, recruitment, training and role of ASHAs, implementation of the Janani Suraksha

Yojana (JSY) scheme, upgrading of CHCs to Indian Public Health Standards, and

operationalising of FRUs.

9. The States have constituted State and District level Programme Management SupportUnits and, to varying degrees, contracted management support staff, including CharteredAccountants, for the units and provided them with induction orientation/training (details provided

in Annex IV). The Financial Management Group (FMG) at MOHFW has been supporting States

through provision of guidelines/ manual and training.

10. The States have undertaken serious efforts in improving convergence with ICDS, such asRajasthan, Madhya Pradesh. They are also moving to work closely with the State AIDS Control

Organisation.

11. As required under NRHM, states are making genuine attempts to establish Rogi KalyanSamities or equivalents. The States have reported the formalities of RKS at the District / CHC /

PHC levels. The State wise progress in establishing RKS is provided in the individual Statereview sheets.

12. As internationally acknowledged and reflected in the national PIP for RCH, a wellfunctioning FRU is critical for ensuring timely management of life threatening obstetric

complications. All states have identified this as a prominent strategy in their PIPs (See individual

State Reviews in Annex III). As per the MOHFW guidelines, the States have initiated the facility

surveys to identify the facilities to be upgraded to FRUs. The immediate challenge for the States

is to operationalise the FRUs in a phased manner such that at least one FRU in a block (other than

district hospital) is functional by the end of the first year.

13. In response to the critical shortage of specialists in anaesthesia and obs/gyn, the MOHFWhas developed short-term training of medical officers in life saving anaesthetic skills for obstetric

emergencies and management of obstetric complications (including C-sections). The MOHFW

has also taken the approval of the MCI for the specialised anaesthesia training.

14. The States agree with the importance of M&E for effective implementation of theProgramme. The MOHFW has prepared a reporting format under the framework of NRHM, and


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the states have started re-aligning their existing monitoring and reporting systems to provide

information in this format.

15. The States were to select 40% of their first year requirement of ASHAs and initiate theirtraining by March 31, 2006. To date, the progress on this has been encouraging over all the States

as numbers of ASHAs have been selected. A key objective of the RCH II Programme is toincrease the quality and coverage of services to vulnerable groups (VGs) in order to reduce the

disparities in outcomes. States have initiated some preliminary activities to improve access to

VGs, including urban slum projects, outreach for remote areas, tribal health projects, and

rationalisation of infrastructure and manpower, and a lot still remains to be done on this front.

16. As envisaged in the National PIP, special emphasis for partnership with the private sectoris key to ensure expansion of service delivery. This is also a critical component of the State PIPs.

States such as Gujarat, Madhya Pradesh, West Bengal, Arunachal Pradesh have initiated PPP

pilots through contracting out of facilities, referral transport systems, IEC, etc., as well as

contracting with the private providers for service delivery to the BPL families.

17. Overall, there is evidence of widespread enthusiasm and optimism in the health sectorsince the launch of the RCH II Programme, and States are moving to put the necessary structures

and systems in place to support a more flexible and comprehensive sector-wide approach. There

is also a clear commitment from the Development Partners to support the sector wide move and

to align resources and programme interventions so that they contribute to the national and State

government priorities. The collaboration observed in designing and carrying out the Joint Review

Mission was most impressive and encouraging.

18. However, several challenges remain and these need to be addressed to accelerateimplementation of this critical programme. The identified challenges and agreed ways to address

them are discussed in detail in the following sections. The detailed status in each area along withthe agreed actions is provided for each State in attached Annex III.

Key Issues and Suggested Actions to Be Taken on the Focus Areas

Governance / Programme Management / Convergence

19. The launch of NRHM and merger of health and family welfare Programmes underNRHM (including RCH II as a major component), has been a welcome step to move towards a

sector-wide approach. The States do require further clarity on convergence of RCH II within

NRHM, especially at the district and sub-district level. This was clearly observed in the Statevisits to Assam and Chattisgarh, and other States also reported this.

20. The biggest challenge observed is the limited capacity to manage such a comprehensiveand holistic Programme. This has slowed the whole progress in implementation of the PIPs, even

of those activities planned for the first year. A lot of progress has been made in the States

regarding the establishment of State and District Programme Management Units, however, there

are still vacancies in these units. In the erstwhile 8 EAG States, out of 35 State level positions 23


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have been filled (66%), while out of 792 district positions around 400 have been recruited to date

(50%) though many more are in the process. In the 8 NE States, out of 32 State level positions, 17

have been filled (53%), while out of 258 district positions, only 81 have been recruited to date

(31%). In the remaining 2 high focused States (J&K and HP), out of 8 State level positions 4 have

been filled, while out of 78 district positions, 24 have been recruited to date. It has been observed

that State government rules and regulations, such as reservation rosters and, in the case ofManipur, cabinet approval, have impeded progress in establishing these units. In addition, the

need for clarification of the roles and responsibilities of the consultants and the relationship of the

management units with the Directorate of Health & Family Welfare has been identified as an

implementation constraint.

21. Some States such as Madhya Pradesh, Chattisgarh, Rajasthan, Uttaranchal & Sikkimhave prepared the District Action Plans (DAPs) for all districts. However, during the field visit in

Chattisgarh, it has been observed that the process of consultations with different stakeholders, as

envisaged under the paradigm shift of RCH II, has not been adequately addressed during the

formulation of the plans. Overall, in the 8 EAG States, 118/264 DAPs have been developed

(45%), and in the NE States, the figure is 27/86 (31%). The comprehensive development of theremaining DAPs should be an absolute priority for States so that funds can be appropriately

allocated accordingly. The DAPs will need to identify the underserved population and propose

additional, special strategies to improve access and use of essential RCH services among

underserved and marginal populations, as also the SC/ST. A portion of the budget provided to

districts could be made flexible to develop and implement innovations specifically aimed at

improving the provision of services for vulnerable groups. The DAPs prepared by the States for

RCH II are now required to be based on the NRHM framework and should synchronise with the

state PIPs.

22. The concept of convergence of externally aided Programmes has been well understood bythe States. However the understanding needs to be translated into action in the preparation ofDAPs. Convergence with other departments, however, has been limited in most States, apart from

Madhya Pradesh and Rajasthan where convergence with ICDS has been well established, and in

Tamil Nadu, which has institutionalised convergence with HIV/AIDS. For other States, this

should be a priority for the next few years as several States in India are facing the possibility of a

serious HIV epidemic, with spread to rural and low-risk populations. Only a few States are

beginning to rationalise the resources available under different vertical Programmes so that

individuals appointed for one task can be more efficiently utilised for multiple tasks

23. To date, most States have registered the RKS. A total of 148 have been registered at theDHs and 2211 registered at the CHCs and the SDHs. There has not been much progress in this

regard, in States such as Jharkhand, UP, Orissa and Jammu & Kashmir. Moreover, theoperationalisation of the samities under the NRHM framework is yet to take place. For example,

the samities in Rajasthan have taken over responsibility for maintenance of the facilities and

equipment as well as providing drugs for the BPL population. However, this needs to be

expanded all over the State and at all levels of facilities up to PHCs. Issues such as availability of

core funds, pro-active executive committees, are constraining the full functioning of the RKS. To

address these constraints, the State governments have been advised to contribute to build up the

resource base of RKS, if adequate funds are not being generated. All funds generated from


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diagnostics and laboratory tests should also be added to RKS, and these funds are to be used for

maintenance and upkeep of facilities, and contracting short-term staff such as the data collectors.

In addition, the States will also need to empower the committees through adequate official orders.

Funds Flow and Financial Management

24. Up to December, 2005 Rs.1455.65 Crores have been transferred to the States under theflexible pool (including parts (A) RCH, (B) Additionalities under NRHM & (C) Immunization

and Polio), based on the approved PIP and Annual Work Plan during the financial year 2005-06.

This, together with the opening balance of Rs.166.55 as of April 1, 2005, available with the State

under RCH-I, aggregated to Rs 1622.20 Crores. The expenditure reported by the States till

December 31, 2005 is Rs 276.18 Crores under the same parts (A), (B) & (C). (17 % of the funds

available). The low level of expenditure reported is a combination of low level of expenditure

incurred (as the funds were transferred only in the middle of the financial year) and expenditure

incurred, but not yet reported.

25. Funds are now being transferred electronically to the States and this has considerablyreduced the lag in delay in release of funds post approval. The releases are now reaching

States/UTs within 2448 hours as against the earlier 1-2 months. This is a good initiative and the

States should explore the possibility of adopting similar process for transfer of funds to the

districts (see Annex VI for details on e-banking). A list of auditors from the CAG has been

circulated to the States for audit for the year 2005-06. The States and the Districts are still to

complete the institutional strengthening aspects (technical and staffing not yet complete in many

States, lack of effective understanding and use of the financial delegation with consequent delays

in the approval process, lack of administrative rules for issues such as TA/DA, etc.), which are

affecting the implementation and utilization of funds.

26. The key issues emerging from the presentation by the State and discussions, on whichaction is required are as follows:

27. Issues at the MOHFW level:a) Further strengthen the FMG (staff and infrastructure) to build its capacity to monitor/ review

internal control procedures and provide training/ hand-holding support to the State andDistricts at least in the initial years, which is critical to effective utilization of resources. The

FMG may also have a Section if found feasible by the Ministry so that files/records are

kept there. The file numbers, opening of files, docketing, and issue of letters, etc., can bebetter handled by a Section only in the Government. The possibility of outsourcing the

management audit function to an external agency may be explored as done under the SSA/

PMGSY Programmes.

b) Funds for certain activities at the State level (e.g. IEC, Training) are still being released bythe respective technical departments as earmarked funds and are not transferred as part of the

flexible pool. The MOHFW may need to release this as a part of the overall flexible pool inorder to synchronise the financial reporting and administrative requirements of this with the

existing financial management system. Also, in the current year, Immunisation, JSY and

Sterilisation Compensation would be separate budget heads as these Divisions are notagreeable with the combined budget head.


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c) The Ministry may prepare a six monthly report on the financial progress of activitiesimplemented at the Central level (such as BCC, procurement of drugs, Monitoring and

Evaluation, training etc).

d) To comply with the revised General Financial Rules provisions, the MOHFW will inform theStates that UCs, even if provisional, may be submitted immediately after the close of thefinancial year, so that funds flow for the next financial year may be maintained. The audited

statement may come later.

e) States have pointed out that it is difficult for them to submit SOEs for activities such asrepair/renovation within a 3-4 months time frame after release of funds. The MOHFW will

need to consider a different set of norms for submitting SOEs and UCs for these types of

activities.

f) The consolidated FMR for the period ending September 30, 2005 was reviewed and thefollowing issues were identified which need to be addressed:

The opening funds available (as on April 1, 2005) may be reflected in the report Expenditures financed by non-pooling DPs, if included in the FMR maybe identified

separately

All States need to forward their FMR (e.g. Delhi has not submitted its FMR) and the levelof compliance by districts needs to be ensured by the States.

The basis of reporting expenditure by States and consistency across States/ districts needsto be reinforced.

28. Issues at State/District level: The States need to accelerate the recruitment process of professionals (UP/ Bihar still in

process of doing so). The States also need to ensure role clarification so that theconsultants are utilized effectively.

State level society mechanism is still being predominantly used for maintaining bankaccount outside the government system. The whole gamut of simplified procedures and

delegation of financial and administrative powers needs to be effectively utilized.

States need to utilise the cap of 6 % of the approved PIP for Programme managementcosts. They may also consider using these funds to provide block level management

support for Programme implementation. This needs to be included in the revised PIP.

With regard to financial reporting the States need to ensure a system of monthly reportingof expenditure from District to State. This is leading to a defaulting of States in sending

their quarterly Financial Management Report to the MOHFW.

29. These issues need to be addressed quickly and it was agreed that a time bound action planwould be sent by all the States by March 31, 2006. For a detailed annex on the FM issues refer to

Annexes V and VI.

Technical Interventions

Maternal Health


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30. Universal access to skilled attendance at birth and increasing access to quality emergencyobstetric care (BemONC and CemONC) remains critical for reduction of high levels of MMR in

the country. The Maternal Health division has produced a set of guidelines providing

implementation details for Operationalising FRUs, blood storage centres, and 24-hour PHCs. In

the 8 EAG states, 700 CHCs have been identified for upgradation to FRUs, and of these 137 havebeen operationalised. Nine States have completed the facility surveys. However, States such as

Bihar, UP, Orissa, Punjab & NE States, require further assistance in conceptualising, planning,

and implementing all aspects of provision of EMOC. This includes support for mapping of the

facilities and identifying facilities for FRUs as per the Guidelines issued by GOI both for FRUs

and for 24-hour functioning PHCs.

31. Needs assessments of identified facilities for infrastructure up-gradation is in the progressin a number of States, while such needs assessment will indicate the nature of civil works, other

aspects such as design and layouts, and developing the budget, will also need to be done by the

States. States could use district resources created with HSDP for civil works so as to expedite the

pace of constructions and also ensure quality. The States should plan for all componentsconcurrently, for example, human resource planning, blood banking, etc. Priority attention should

be given to put critical components in place first.

32. Non-availability of specialists remains a problem despite provisions for contractualappointments. As discussed earlier, States need to revisit the remunerations being offered, as

these need to match with the market salary. The impact of nursing staff shortages (especially staff

nurses and female multi purpose workers), and mis-match in deployment was quite evident

during field visits to Assam, Chattisgarh and UP. It is suggested that the States should (i) Rank all

facilities in the district based on utilization rates and undertake a rapid facility needs assessment

of higher ranked facilities; (ii) First provide missing critical inputs to those facilities being used

most, and then develop innovative programmes and NGO partnerships to reachvulnerable/underserved groups. Funds from the RCH II, NRHM and other DP sources should be

considered when deciding to make any changes or renovations to the FRUs. In addition the

ASHAs will need to be linked up to the PHCs providing 24 hours delivery service or CHCs for

CEmONC. As has been done by Tripura and Assam, women with GNM training could also be

recruited for the 24-hour facilities. States facing shortages of nursing personnel may consider

increasing number of seats in existing GNM courses.

33. GOI has approved the organisation of trainings for Medical officers in life-savinganaesthetic skills for obstetric emergencies. States are following up on this by working with

medical colleges to organise trainings. Similarly to overcome the shortage of Obstetric specialists,

an innovative training programme to be steered by the FOGSI-AICOG has been approved. It willbe useful to assess effectiveness of such a training programme and closely watch its

implementation. Alternatively FOGSI may also be requested to set up clinical training facilities

outside the public sector at big corporate hospitals to cater for huge training loads. Gaps in

availability of nursing personnel for 24-hour functioning centres are emerging as a problem in

some of the high focused States. It will be useful to augment admissions for GNM courses or

open new schools, although this will be a longer-term solution.


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34. Guidelines for antenatal care and Skilled Attendance at Birth, and Management ofcommon obstetric complications have been developed. It is encouraging to note that, as a first

step, States are going ahead with organising of nursing trainings as on the job trainings starting

from district hospitals, CHCs and then training Sub-centre ANMs. It will be crucial to focus on

quality of trainings and post training follow-up. GOI has already constituted a central monitoring

committee to monitor these trainings. The Committee should also look into the readiness oftraining sites in adhering to new technical guidelines (such as use of partographs) and help States

with problems in terms of identification of training sites, TOTs, organisation of training plans,

and post training follow-up. Contents of kits to be supplied to the peripheral facilities should be

consistent with technical guidelines. Essential drugs should be made available to SBA as soon as

training is completed.

35. Several States have begun the implementation of the JSY scheme, but the state like UP,needed further clarifications regarding implementation of JSY, which were explained to the State.

The Ministry released Rs.50 crores to the States as 1st

Instalment for JSY through RCH Flexi

Pool mechanism. The expenditure figures received from some states (upto 3rd quarter) indicate an

expenditure of around Rs.32 crores. The states namely Andhra Pradesh, Tamil Nadu, Rajasthanand Himachal Pradesh has requested for additional funding for JSY, which is being considered in

the Ministry. Although the Ministry had circulated to the State an FAQ document on JSY to the

States there is need for issuing further clarification on various issues revised by the States on the

subject.

Child Health

36. The implementation of interventions for child health has been slow in most of the Statesdue to the fact that the capacity-building interventions are time intensive. IMNCI has been

accepted as the preferred strategy, however this has cost and time implications. One way ofaccelerating implementation would be through training the ASHA/AWW to be responsible for the

two components of IMNCI that are to be implemented at the household and community level.

This would to some extent, help address the immediate causes of neonatal mortality. A detailed

training plan needs to be developed subsequently. The remaining part which is facility based

could then be implemented as soon as the upgraded facility, trained personnel and equipment are

made available at each facility. The Government of India has yet to finalize operational

guidelines for IMNCI implementation, although pilots have been undertaken in some districts of

the country. It remains to be seen how large number of trainers and trainees can undergo quality

training within the stipulated period of time leading to skills development and provision of

services as per protocols. Most OPD care for sick children is sought in the private sector and there

should be a strategy to reach out to private practitioners. While IMNCI is being rolled out, dueemphasis should be given to existing child health interventions, such as ARI, diarrhoea

management, and essential newborn care in other districts.

37. The Multi Year Strategic Plan (MYP) for Universal Immunisation Programme is in place.Additional funds have been allocated for implementing this Programme. A number of new

interventions have been introduced by the GoI to give a boost to the program i.e. additional

mobility support, taking ANMs on contract, support for field monitoring, review meetings etc.


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New technologies have been introduced (AD syringes, 10 dose BCG vial, etc). A training plan

has been developed to acquire new skills. An electronic system for monitoring progress has been

developed.

38. The State review indicated that States have started imbibing the Guiding Principles of theMYP in varying degrees. While there have been good initiatives on micro-planning andintroduction of AD syringes, many States have not yet articulated plans for alternate vaccine

delivery and community mobilisation. On-site supportive supervision also needs to be

strengthened uniformly across the EAG States. Reports are not being submitted from the States in

a timely manner and hence the gaps are not being addressed quickly. In general, the micro-plans

need to prioritise unserved and under served populations in each district for enhanced

immunisation activities. It was encouraging to note that the EAG and North-east States have

started implementing an Immunisation week every month from Jan-March 2006, as a catch up

activity. This is showing some positive gains in the short term. Some States have reported

increase in immunisation coverage (e.g. Assam; for details, see States annex III).

Family Planning

39. GOI has made allocations for organization of NSV camps and issued guidelinesaccordingly. Performance is highly uneven in the States. In some States, such as Punjab, Haryana,

Madhya Pradesh, Rajasthan and Jharkhand, the programme has picked up very well and a

sizeable number of providers have been trained, while in many other States progress is not

satisfactory. Overall there is greater appreciation in the States for providing NSV services through

static facilities. This is encouraging, particularly in view of the gender aspects of increasing male

involvement in reproductive health. During field visits it was noticed that there is high load of

clients for sterilisation services. States need to take initiatives for enhancing the pool of trained

human resources for conducting female sterilization including minilap and laparoscopy, increase

the number of static service delivery sites, and offer services on a regular basis around the year.There have been a number of failures/deaths following female sterilization in some of the States.

These issues have come up in public hearings being organized in some States under the aegis of

NWC and SWCs. In light of the Supreme Courts directions, GOI has revived QA committees at

the State and district level. The detailed guidelines for monitoring service quality and conducting

audits by QA committees are under formulation and will be disseminated to the States. These

guidelines will also be used for monitoring quality of services by private providers under PPPs.

GOI has also introduced a Family Planning Insurance scheme for acceptors of sterilizations and

indemnity cover for doctors (including private doctors) performing sterilizations. This should

address fears of litigations by doctors in the event of method failure. In high focused States the

majority of sterilizations are done in camp settings. Evidence from the field indicates that States

need to emphasise on quality and standards while delivering the services. Development of SOPsfor the camps will help State and district Programme mangers to plan and monitor service quality

in the camps.

40. It is encouraging to note that emergency contraceptive pills had been made available overthe counter although utilization is still very low. A mass media campaign with support from

industry would help in raising awareness and increase utilization of ECPs. Government of India is


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also awaiting results of injectable contraceptive multi centric study before introducing the method

in the Programme.

41. Private providers are a major source of contraceptive services in some of the States. GOIis very keen to engage private providers in provision of sterilization and reversible contraceptive

services. The States have been encouraged to enrol private providers and initiate mechanisms foraccreditation so as to ensure quality in delivery of services. In order to enhance the knowledge of

service providers (both public and private sector) in adhering to eligibility criteria, informed

choice, method specific counselling, indications and contra-indications, and side-effects

management, a Contraceptive update Programme has been developed and is being

implemented.

42. Updating of service delivery guidelines and sterilisation standards is long overdue. TheMOHFW will need to revise these documents after incorporating new evidence-based

recommendations.

43. Under the large number of initiatives taken in Maternal Health to reduce MMR, one ofthe initiatives is training Staff Nurses and ANMs in ante-natal care and skilled birth attendance.As spacing and terminal methods are best accepted in the immediate post-natal period, the

importance of imparting contraceptive training along with this training is manifold and needs to

be incorporated with the skilled birth training. Out of the total period assigned for skilled birth

training one day on contraceptive update could be provided to these trainees.

44. One initiative, within the large number of those undertaken in Maternal Health, is thetraining of Staff Nurses and ANMs in antenatal care and skilled birth attendance. As spacing and

terminal methods are best accepted in the immediate post-natal period, the importance of

imparting contraceptive training along with this training is manifold. Out of the total period

assigned for skilled birth training, one day on contraceptive update could be provided to thesetrainees.

Adolescent Reproductive Health

45. A National Consultation on RCH II ARSH Strategy: Development of NationalOperational Guidelines was organized on 2-5 September 2005. As an outcome of this

consultation, an implementation guide for the Programme managers is under finalisation and will

be disseminated to the States thereafter. Similarly, the IEC division in the Ministry is also

working on finalization of training material, which has been pre-tested in three States of the

country. It is envisaged that rolling out of interventions under this strategy should begin once

these documents are disseminated to the States and Programme managers are oriented in the use

of these guidelines. Presently, States have yet to initiate planning for ARSH activities as the

central guidelines are awaited.

Innovations


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46. Pilot PPP interventions have to be prioritised for districts with higher vulnerablepopulations, and SC/ST groups. In addition, health insurance schemes would need to be piloted to

ensure that all discussed models are tested prior to implementation.

47. States should consider flexible budgets to districts for preparing and implementinginnovative actions including partnerships with NGOs and the private sector to improve the use ofRCH services by the identified vulnerable groups. Innovations in several States to accelerate

service delivery were showcased during the review. These include the following:

UP - 5000 Gram Pradhans are being sensitised on gender issues. Orissa Health institutions resource mapping is undertaken using GIS HP (i) Panchayats provide telephones for PHCs free of charge and maintenance

cost is borne by the PHC; (ii) Rs 30, 000 provided to FRU as untied fund as

emergency referral transport;

MP (i) Assembly members are being sensitised about RCH; (ii) Bal SanjivaniYojana scheme for identifying malnourished children and providing adequate

nutrition; Bihar (i) Established a data centre for daily monitoring of OPD output by each

participating institution; (ii) 8000 villages covered with mobile medical units for

underserved population

Uttaranchal (i) Gram Pradhan sends pre-addressed postcard for feedback onservices in camps, including suggestions for improvements; (ii) documentation of

practices on traditional healers; (iii) effective interventions for monitoring the

outcome of NGO services.

Pondicherry - Family based health cards Gujarat - Chiranjeevi Yojana is a scheme to contract out private providers for

delivery care and management of obstetric complications;

Rajasthan Panchamrit or catch up rounds for 5 interventions (immunisation, VitA, neo-natal care, FP, safe motherhood)

Jhakhand - Detailed strategy developed for block level planning for tribal healthcare

Tamil Nadu (i) Integration of ISM with primary health care systems; (ii)convergence with HIV/AIDS/TB at PHCs

Karnataka (i) remote area allowance for doctors and staff nurses; (ii) healthinsurance for SC/ST population

Haryana (i) use of delivery huts; (ii) quarterly state review with districtmagistrates and CMO; (iii) telemedicine project to develop village development

resource centre at CHCs

West Bengal - ranking of Blocks as per key health indicators

Arunachal Pradesh PHCs contracted out to NGOs and private practitioners

Equity, Access and Coverage


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48. If the goals of RCH II are to be achieved each State needs to undertake a SituationAnalysis to map the key indicators for IMR, CMR, % of underweight children and Institutional

Delivery as well as immunisation rates and other key available data (as in RHS). This needs to be

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. This should also

include a map of the distribution of existing human, financial and infrastructure resources. Thiswill identify priority areas and vulnerable groups and provide the basis for rational allocation of

resources to reduce disparities. The Situation Analysis should be included in the PIP.

49. With support from USAID, an Urban Health Resource Centre was set up in November2005, as the Government of India designated nodal technical agency for guiding and helping the

States in designing and implementing urban health projects. The national guidelines for

operationalising the urban health strategy are available to Programme Managers at State level. It

would be critical to involve the vulnerable groups also in the planning process and also bring

them on board in the process of community monitoring. Some States have gone ahead and

developed urban health plans as an integral component of RCH II Programme. States have been

advised to develop plans targeting urban poor living in cities with more than 100,000 populations.The smaller sized cities (less than 100,000 population) should be covered within the District

Action Plan being developed in the RCH Programme. For effective formulation and

implementation of Urban Health strategies, States should have an exclusive/dedicated Urban

Health cell at both the State headquarters level and at the concerned sub-State levels provisions so

that the cities selected has UH projects.

50. The Tribal Health strategy has been reflected in the national PIP and has been evolvedafter consultations with stakeholders. There has been very little progress so far on this front and

none of the States has submitted plans for tribal areas.

51. The Accredited Social Health Activist (ASHA) is a major strategic intervention underNRHM. ASHA is envisaged as a trained woman community health volunteer who will inform,

interact, mobilize and facilitate improved access to preventive and promotive health care and also

provide basic curative care through her drug kit. The selection and training process of ASHA has

to be given due attention by the States in adhering to the criteria of selection as detailed in the

guidelines from the Government of India. The States such as Chattisgarh, Jharkhand, Rajasthan

and Uttar Pradesh have registered considerable progress in the selection and setting up of the

training systems for ASHAs like the constitution and training of State Training Teams (STT),

District Training Teams (DTT) and Block Training Teams (BTT). Till date, 100,000 ASHAs

have been selected in the 10 high focus States. Capacity building of ASH is critical in enhancing

here effectiveness. The training for ASHA shall be initiated by the states as soon as their selection

is complete. The mechanism for monitoring ASHA will also need to be implemented.

52. The Anganwadi worker and ANM will be the mentors for ASHA and will work in closecoordination. If any State desires to have a community based female voluntary health worker, it

may be encouraged and the State may be advised to reflect the same in its PIP.

53. As ASHA has been envisaged as a primary resource for the community on health issues,she needs to be actively engaged on development of village health plans along with the


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panchayat, womens group members and other health functionaries. Hence it is advised to

organise joint training for the village health teams. Reputed NGOs working in State/districts

should be involved in the training of ASHA as envisaged in the guidelines.

54. During the review process it was evident that States lacked clarity on the role of theMNGO scheme and had not completed the selection of MNGOs/ FNGOs. This should beaddressed as a priority. In the revised State PIPs due emphasis should be given to involve the

selected MNGOs and FNGOs in the implementation of RCH II activities. Current vacancies of

the State NGO co-ordinator should be filled up on priority and integrated within the State Health

Society. Similarly District Health Society should include the MNGO as a member.

55. Overall, mechanisms that have been put in place with DWCD, PRI Ministry and NACOneed to be intensively reviewed at all levels to ensure that they are functional, synergistic and

collaborative in enhancing service access and outreach. Towards this end, these

departments/ministries/bodies should be involved suitably in the review process.

Monitoring & Evaluation

56. The M&E Unit in the MOHFW was responsible for initiating action on the followingmajor activities: definition of the MIS, piloting quality assurance mechanisms in selected

districts, development of a methodology to assess the management capabilities of State and

District health system for implementation of RCH II/NRHM and evolving a process of

community based monitoring and triangulation of data. Apart from the above, conducting surveys

such as NFHS, DLHS and PRC specific-studies have been planned.

57. The M&E unit has worked on the MIS format (State to Centre), which was circulated tothe States for their comments before its finalization and only two States have provided their

feedback until now. The M&E Division is now planning to hold a meeting of the StateDemographers/MIS Officials in April 2006 to assess the functional status of current reporting

format sent by Govrnment of Indial. While finalising the new NRHM format, a decision on

discontinuation of all older reporting formats should be taken.

58. On the topic of Quality Assurance (QA) the M&E Unit has held a workshop and tworounds of meeting with a working group consisting of representatives from different Programme

divisions and development partners for evolving the process of initiating QA pilots. The terms of

reference were finalized and ratified by the group and it was decided to develop an integrated

manual for initiating QA pilots. This process is underway and the pilots should be started in about

3 months time.

59. Regarding methodology of Programme management assessment, the States of Gujaratand Rajasthan were selected for piloting. IIM have completed the study in Gujarat and will be

covering Rajasthan soon. Subsequent to completing Gujarat, IIM shared the preliminary findings

and an interim report. The Rajasthan study will be completed by April, 06 and a manual on

Programme management assessment would be made available by IIM by July, 06.


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60. On the evaluation front, the DLHS II reports were finalized and activities on DLHS IIIhave been initiated. This apart, the NFHS III is ongoing and more than 10 States have been

covered in the first leg. The TOT for agencies for second phase has been completed and the

second leg of fieldwork would begin by April, 06.

Training / BCC

61. It is recommended that the training plan should be integral to a comprehensive HR policyto be developed by each State. It is suggested that infrastructure development division engaged in

reorganization pf public health care delivery system should also examine human resource

requirement at different levels of care and review the job responsibilities.

62. The draft Operational Guidelines for trainings in RCH II provides useful information fordeveloping comprehensive State training plans. During the discussions held at various levels, the

need for integration of different types of trainings was emphasized. Concerns related to disruption

in services due to frequent trainings for service providers should be addressed by integrating

trainings wherever feasible, such as in clinical trainings.

63. However, for effective implementation of training plans in the context of NRHM,management of trainings needs to be strengthened. Considering increasing involvement of

medical colleges and the multitude of training institutions in the public sector, a strategic

approach is needed. This will entail formulation of guidelines spelling out scope of training,

infrastructure needs, HR requirements, and linkages with the health systems, maintaining data on

training, which are supposed to be the clients of these institutions.

64. NIHFW has been conducting Professional Development Course for enhancingmanagement capacities of the district level health managers since 2002. It will be useful to assess

effectiveness of this short-term training Programme in the field, which will also provide inputsfor making necessary changes in the Programme if needed.

65. Training division in MOHFW and training cells in the states need to be strengthened forsteering implementation of national and state training plans, and monitor outcomes of trainings,

in terms of improved service delivery.

BCC

66. As reflected in the National PIP, mass media activities have been initiated leading tobranding of NRHM. Significant efforts are on to publicise NRHM. Two issues of NRHM

newsletter (with print order of 2 lacs in English, Hindi, Urdu and other regional languages) arepublished and initial response to the newsletter is encouraging. However, the field visit revealed

that providers at district level and below are not fully acquainted with the scope of RCH II/

NRHM.

67. During the review it was observed that States are implementing IEC activities as perearlier plans without any comprehensive BCC strategy. States will need support for developing

and implementing a decentralized BCC strategy.


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68. National level mass media activities will have to be supported with inter personal andgroup communication activities in the districts for achieving sustained change in behaviour.

Hence, the States and District BCC strategy should take into cognizance the cultural diversities

and media penetration.

Technical Assistance

69. The need for technical assistance to implement the RCH II Programme has been clearlyidentified throughout the design period. Suggested mechanisms to provide such TA have been

proposed through a National Health Systems Resource Centre (NHSRC), a Regional Resource

Centre for the North East States (NE-RRC) and possibly other similar regional centres, and State

level Health Resource Centres (SHRC), where needed. In addition, States are recruiting their own

TA as contractual staff for the Programme Management Units at State and district levels (SPMUs

and DPMUs).

70.

In December 2005 a retreat was held with GOI, selected States and Development Partnersto reach agreement on the proposed arrangements for the NHSRC based on the concept note of

the GOI. This note focuses on the needs for TA in the context of the entire NRHM and not only

for the RCH II component, and calls for greater convergence of partner support. DPs identified

the geographic and thematic areas where they could contribute assistance. The final proposal for

the NHSRC indicates an autonomous society mechanism to be physically located in the NIHFW

with co-funding from GOI, DPs and possibly other sources.

71. The NE Regional Resource Centre has been established in Guwahati, Assam sinceNovember 2005 as an autonomous institute to provide technical assistance to the NE States in the

implementation of the NRHM. It has the following identified roles:

Facilitate situational analyses

Promote evidence based health planning Identification of vulnerable groups Assist in the organisational restructuring of directorates to enable integration Facilitate integrated and equitable planning & management at State & district levels Assist in strengthening financial management systems Promote devolution of financial & administrative powers Strengthen procurement systems Promote standardisation of norms at primary & secondary facilities Assist in HMIS and M&E strengthening Facilitate institutionalisation of mechanisms to strengthen participation of groups with

less access to existing services

Facilitate mainstreaming of tribal medicine systems72. A hub and spoke arrangement allows for a team of experts to be based in Guwahati andprovide assistance on a needs basis to all States, while a State Facilitator will work on a day-to-

day basis with the individual State directorates. The NE RRC will not replace the role of the

Government of India, but will provide the additional TA required. As the full complement of staff


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are yet to put in place, it is too early to assess how effective this arrangement will be, but the

situation should be closely monitored so that the potential impact can be fully realised.

73. During the State review it was evident that those States that had used external TA well,had made considerable progress on specific areas, e.g. Madhya Pradesh with DFID support has

been one of the only States which have developed plans for all districts along with RCH II StatePIP. Similarly, those States with Health System Development Projects supported by the World

Bank had managed to address Waste Management issues in a comprehensive manner. Likewise,

Assam has addressed the issue of strengthening FRUs well, as it has the ongoing support of the

EC in doing this. In the absence of a sustained and co-ordinated TA mechanism (NHSRC),

existing TA modalities should continue. In addition it is recommended that joint

support/facilitation teams should be set up (GoI +DP +well performing States such as Tamil

Nadu)) for each of the EAG States to provide implementation support and accelerate the pace of

the Programme.

74. Suggested Action Points from the Chairperson of the High Level ReviewsGovernance / Programme management

The MOHFW to finalise the NRHM implementation framework and provide detailson the scope, modalities and procedures in order to ensure that there will be the

desired convergence by 2007

The lagging States will need to expedite filling the remaining positions stipulated inthe PIPs for the SPMUs and DPMUs, and complete the orientation training. This will

enable staff at the lower levels of implementation to be fully informed and supported

about new modalities. This is especially important for the untied funds to be accessed

and used in a flexible way, as desired.

The development of the remaining DAPs should be completed urgently so thatresources can be appropriately allocated to the most needy areas

A Joint Secretary has been appointed at central level to assist all the high focusStates for implementation of NRHM. This resource should be more effectively used to

help States and can be supplemented with additional support from DP & other

States.

State governments should consider providing additional funds for RKS if necessary,and empower these bodies especially to ensure vertical equity in health financing

Convergence needs to be more comprehensively addressed by most StatesFinancial Management

MOHFW should consider releasing 75% funds to the States at start of FY More clarity on FM procedures needs to be provided to all levels States must provide at least provisional UCs on the 1st year funds, or they will not be

able to access the 2nd year funds

States need to provide an overview of funds flow, including amount allocated,received, utilised and remaining so that MOHFW can calculate the next release.

Audited statements can be provided later


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Technical Interventions

The need for any new construction should be justified. States should first focus onmaking existing facilities functional, particularly those that are almost functional but

are lacking a few critical inputs. This is especially important for making the FRUs

operational. Use of prefabricated buildings should be considered while planning

renovations and additions to the existing facilities. More clarity on the JSY scheme should be given at all levels and mechanisms for

making it functional instituted immediately.

States should phase out the operationalisation of IMNCI so that the implementationof the household and community level interventions is accelerated

Equity & Access

ASHAs need to be linked to a facility and well supported by the team at the PHC Urban health & tribal health plans need to be included in the PIPs so that approval

is obtained for all at same time and additional approval is not required for specific

plans

An analysis of policy lessons from States that have succeeded in identifyingincentives and policies to encourage Medical and Paramedical posting in

underserved areas should be undertaken and the recommendations disseminated

Training

All States need to prepare a comprehensive training plan and send it to NIHFW andtraining division of the MOHFW. of GOI for information

Decisions/ observations made during the wrap up session on JRM held on 10.4.2006.

1.

States need to Identify indicators related to underserved, region and population vis a visactivities planned under District Action Plan (DAP).

2. District lacks capacity to prepare DAPs, more TA support is needed at district level.This is to ensure the quality of the DAP.

3. The guidelines for preparation of State PIP issued by this Ministry needs to beconsidered by the state for preparation of DAP and for its appraisal and approval

process.

4. The Ministry has decided to see that all the states / UTs complete their preparation,appraisal and approval of DAPs within six months. The support from all the

development partners, International agencies and MNGOs may be visualized for

completing the task.

5. The M&E division of the Ministry will ensure that the complete information as per thetwo rounds of Rapid Household Surveys (RHS) surveys on all the Districts will be madeavailable to all the States/ UTs. This is to provide sufficient baseline information to

prepare DAPs.

6. The Ministry requested all the States and UTs to prepare a comprehensive training planincluding all the training components from all the interventions such as CH, MH, IEC

etcAlso the States are requested to emphasize on the important three training

programmes such as training on Anesthetist, SBA, and training on EmOC.

7. The States need to fill up their posts in Programme Mangement Units (PMU) and othercontractual Medical Specialist, vacancies by September 2006.


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8. The Ministry may establish on line help line to provide assistance in programmanagement to all the States and UTs for RCH II.

9. The following requires a thrust areas to be taken up by the States States need to use the untied funds for operationalisation of Sub Centers. ASHA need to be linked with a facility and the MO at the concerned facility

needs to be trained and aware of the related ASHA.

A thrust can be provided by the States to improve the services of the DistrictHospital to make it completely functional.

States need to prioritize the IMNCI strategy for implementation with thrust atcommunity level which may be adequately be addressed in the RCH II PIP.

States need to assess their management requirement at Block level, which need tobe addressed in RCH II PIP.

MOU need to incorporate related provisions to ensure the establishment andfunctioning of PMUs at both the State and District level.


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Priority Actions

(March 2006-January 2007)

Issue ActionsResponsible body Time frame

Governance/

Programmemanagement/

convergence

Finalise the NRHM implementation

framework and clarify the procedures andregulations 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

Finalise DAPs so that resources can beappropriately allocated to the most needy

areas

Disseminate support team names & contactdetails to each State

Provide additional funds for RKS if

necessary, to make them more functional

Address convergence more

comprehensively

MOHFW

States / districts

States / districts

MOHFW

State governments

States / districts

31 March 06

31 March 06

31 March 06

31 March 06

April 2006

July 2006

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 atall levels

Provisional UCs to be submitted for 1st

year

expenditure for release of 2nd year funds

Provide overview of funds allocated,

received, utilised & remaining

MOHFW

MOHFW/ States

States

States

Maternal HealthOrganise TA for select HF states to developclear plan for making existing facilities

functional, focusing first on those needingonly 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

MH Division

Respective States

June 2006

June 2006


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Child Health

Family Planning

ARSH

Trainings

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

Finalise and dissemination of operational

guidelines for IMNCI to be used by the

State and District Programme managers

Develop a strategy for engaging privateproviders to enable them using IMNCI

protocols

Organise technical assistance to the select

high focussed States for developing micro-

plans under multi-year immunisation plan.

Finalisation and dissemination of manual

for quality assurance in sterilisation.

Develop a SOP manual for RCH camps

Mass-media category promotion for ECPs

Revision of existing contraceptive service-

delivery guidelines and sterilisationstandards.

Finalisation and dissemination ofimplementation guide for operationalising

ARSH strategy

Finalise training modules for Medical

Officers and ANMs and share with States

Develop HR policies including training.

Comprehensive training plans to be shared

by the States

MH Division

MH Division

CH Division

CH Division

CH Division / States

RSS Division

RSS Division

RSS / IEC Division

RSS Division

IEC Division

IEC Division

States

States

Training Division

March 2006

March 2006

April 2006

June 2006

June 2006

April 2006

May 2006

June 2006

August 2006

April 2006

April 2006

August 2006

April 2006


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BCC

Assessment of PDC Programme

Commissioning a Situational AssessmentStudy of Training Management in health

sector

Develop and dissemination of plans for

strengthening training management based

on the recommendations of above study

Develop and dissemination of operational

guidelines for decentralised BCC strategyaddressing NRHM issues

Organise technical assistance for capacitybuilding of State counterparts to plan,

implement and monitor BCC plans

Training Division

IEC Division

IEC Division / States

IEC Division / States

June 2006

September,

2006

June 2006

July 2006

Innovations Initiate pilots and actions on PPP and other

innovations in the State PIPs.

States July 2006

Equity &

Access/

Vulnerable

Groups

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 andBlock to identify who are the most

vulnerable, where they are and what their

specific/additional requirements are. Mapexisting 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 healthstaff at those facilities

Include urban health and tribal health plansin the overall PIP so that approval is

obtained simultaneously for all

Document success stories in posting staff toremote and underserved areas and share

with other States

MOHFW ,/Chief

Director, M&E

States / districts

States

MOHFW/Director,Area Projects

On-going

M&E/ focus on

outcomes

Finalization of MIS format from State to

centre level

M&E Division April 2006


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Preparatory work for piloting of QA.

Finalization of Programme managementassessment methodology and manual.

Development of methodologies forcommunity monitoring and triangulation of

data

May 2006

July 2006

March 2007

NFHS-III Report, Table, Formats etc.

Completion of Field Work of NFHS-III

Data entry and Processing

A few summary results, all India level only

National & State Report & Dissemination

M&E Division April 2006

June 2006

Oct 2006

Nov 2006

Start by March2007

DLHS-III Preparatory work(Administrative, Technical and

Questionnaire finalisation)

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

M&E Division May 2006

Aug 2006

Sep 2006

Oct 2006-Feb

2007

Jan 2007

March 2007-

June 2007

Nov 2007

Training/ BCC/NGOs

Prepare a comprehensive training plan States

Others TA Set up State facilitation teams

(GoI/DP/States) for enhanced support to

EAG & NE States on a continuous basis (tillNHSRC is set up)

MOHFW April 2006


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List of Annexes

I. ToRs of the JRMII.

Process Manual for the State ReviewsIII. State sheets on key issues

IV. State PMU matrixV. Note on Financial Management

VI. Note on e-bankingVII. Field visit reports

VIII. Note on Equity & AccessIX. State support teamsX. List of participants

Documents

Reproductive and Child Health Programme Phase 2 First Joint Review Mission-777