Guidelines Part 1

8/8/2019 Guidelines Part 1

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II - LETTER OF AS & MD ONPLANNING PROCESS 2010-

2011


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D.O. No. 10 (2)/2008-NRHM-I8 th October 2009

SUBJECT: NRHM-PLANNING PROCESS 2010-2011

At the outset, I would like to convey my appreciation for theinitiative taken by your State in implementation of the National RuralHealth Mission (NRHM). We are confident that a lot of the priorities thatwere set up for the current year shall be achieved under the programme.As part of the preliminary exercise of planning for next financial year, Iwould request the States to carry out a review and focus on some of thefollowing key priorities in the next few months.

2. The exercise of Plan preparation from the Village to the Block to theDistrict and finally to the State PIP required to be scaled up as early aspossible. Based on the assumptions that there would be at least 25percent increase in the allocation of resources in the next financial year, Iwould suggest that the State Governments may work out the resourceallocations for districts as well as for blocks to facilitate Block and Districtlevel planning. The appraisal meetings and consultations at Block and

District levels should be taken up so that the State PIP fully reflects theaspirations of the local level.

3. The planning process for 2010-11 may be initiated in the month of October 2009 as per the following schedule.

State to send Resource envelope to Districts October 2009 District Plans based on Village/Gram Panchayats /Block Panchayat

Samiti Plans December 2009. First Draft PIP before State Health Mission- First Week January 2010.

Pre-appraisal meetings in January up to 15th

February, 2010. Final NPCC meetings between February and 15th March, 2010.

4. The Structure of the PIP would be the same as in the earlier yearswhich would be in five parts as follows; A. RCH Flexible Pool B. NRHMMission Flexible Pool C. Routine Immunisation D Disease ControlProgrammes E. Inter-sectoral convergence. The Infrastructuremaintenance through Treasury Transfer which was missed out earlier inthe structure should be reflected. Activities taken up under other Healthprogrammes (trauma centres, nursing etc) and those supported byexternal agencies like World Bank, DFID and also Finance CommissionAwards should also be reflected.


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5. The detailed progress to be reflected in the PIP should include thefollowing:

I. Progress on infrastructure development.II. Filling up of existing regular vacancies by the State

Government.III. State Governments allocation, release and expenditure under

normal health programmes over the years.IV. Progress of NRHM during 2009-10, (a) in institutional set up

e,g ASHAs, VH&SC, PRIs, RKS, BHS/BHM, DHS/DHM, SHS/SHMetc, (b) in facility operationalisation 24X7 PHCs, SCs, CHC asFRUs, DHs, (c) in DHAPs, MMUs , (d) in fund utilization , (e) instreamlining procurement and logistics, HMIS and training and skill upgradation.

V. Performance under NRHM over the years on key outcome andprocess indicators like IMR, MMR, TFR, full immunisation,institutional delivery, reduction in malaria, filaria, kalazar ,leprosy prevalence, TB cure rate, cataract operation etc

6. The following key areas have been identified for priority action in2010-11;

Clear Action Plan for Backward Districts as part of the PIP - The State must identify backward areas for greater attention

(difficult, left wing affected, minority, tribal, SC/ ST gender etc.). Wewould also request that special incentive to medicos and para-medicos for performing duties in difficult areas, which was part of 100 days agenda of this Ministry may be made part of the State PIPsfor the year 2010-2011.

Clear Action Plan for streamlining of procurement and logistics - Supply Chain Management System, ProcurementManagement Information System (ProMIS) and Rational Drug Use .

To ensure sustainable drug supply at all levels and itsreplenishment, logistic and information systems arrangement needstrengthening on a priority. We would request the States to fullyreflect their plans for strengthening logistic arrangements in thePIPs for 2010-2011.

Clear Action Plan for Operationalising HMIS up to facility level - The States must endeavour to have a road map for webenabled facility based reporting and put in place tracking of information on pregnant mothers and childrens immunization.

Capacity Development of all Institutions crafted under

NRHM ASHA, VHSC, RKS, PRIs, Programme Management Units,MIS etc


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Higher utilization of financial resources under NRHM -Greater thrust should now be on facility specific reporting of progress on expenditure.

Clear plan for human resources for health which shouldinteralia include the steps undertaken by the States in filling upvacancies.

Clear Action Plan on Training and Skill Development aiming ata comprehensive and integrated training plan.

7. The following key priority themes have been identified for priorityaction in 2010-11;

Neo Natal Mortality Facility and Home based care for newborn.Population Stabilization.Malaria.MDR TB.Making facilities family friendly water, electricity, clean toilets,lights, security.Vibrant VHSCs and RKSs.NABH/ISO certification of government facilities.

I am confident that your personal oversight of the planning process

would go a long way in enriching the quality of the Plan in 2010-11.

Yours sincerely,

( P.K. Pradhan ) ToMission Directors, NRHM of all the States(As per list attached)


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III PROGRESS ON REFORMS

AS MANDATED WITH PIP

APPROVAL 2009-2010


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III - PUSHING REFORMS WITH RESOURCESPROGRESS ON CONDITIONALITIES WITH PIP

APPROVAL

2009-2010(Please put Y for Yes and N for No)

1. All posts under NRHM are on contract and based on local criteria. The

contract should be done by the Rogi Kalyan Samiti /District Health

Society. The stay of person so contracted at place of posting is

mandatory. All such contracts are for a particular institution and non

transferable. The contracted person will not be attached for any purpose

at any place.2. Blended payments comprising of a base salary and a performance

based component, should be encouraged.3. State Government must fill up its existing vacancies against sanctioned

posts, preferably by contract.4. Transparent transfer and career progression systems should be

implemented in the State.5. Delegation of administrative and financial powers should be completed

during the current financial year. If not already done.6. State shall set up a transparent and credible procurement and Supply

chain management system and Procurement Management Information

System (PAOMIS) [on the lines of the Tamil Nadu Medical Services

Corporation]. State agrees to periodic procurement audit by third party

to ascertain progress in this regard.7. The State shall undertake institution specific monitoring of performance

of Sub Centre, PHCs, CHCs, DHs, etc.8. The State shall operationalize an on-line HMIS in partnership with

MOHFW.9. The State shall take up capacity building exercise of Village Health and

Sanitation Committees, Rogi Kalyan Samitis and other community /PRI

institutions at all levels.10. The State shall ensure regular meetings of all community

Organizations /District /State Mission with public display of financial

resources received by all health facilities.11. The State Govts. shall also make contributions to Rogi Kalyan Samitis

and transfer responsibility for maintenance of health institutions to


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them.

12. The State shall endeavour to bring the Budget of Health facilities under

the supervision of the concerned Rogi Kalyan Samitis.

13. The State shall prepare Essential Drug lists of generic drugs and

Standard treatment Protocols, and give it wide publicity.14. The State shall focus on the health entitlements of vulnerable social

groups like SCs, STs, OBCs, Minorities, Women, migrants etc.15. The State shall ensure timely performance based payments to

ASHAs/Community Health Workers.16. The State shall encourage in patient care and fixed day services for

family planning.

17. The State shall ensure effective and regular organization of Monthly

Health and Nutrition Days and set up a mechanism to monitor them.18. All performance based payments/incentives should be under the

supervision of Community Organizations (PRI)/RKS.

19. The State agrees to follow all the financial management systems under

operation under NRHM and shall submit Audit Reports, FMRs, Statement

of Fund Position, as and when they are due. State also agrees to

undertake Monthly District Audit and periodic assessment of the

financial system.20. The State agrees to fast track physical infrastructure upgradation by

crafting State specific implementation arrangements. State also agrees

to external evaluation of its civil works programmes.

21. The State Govt. agrees to co-locate AYUSH in PHCs/CHCs, wherever

feasible.

22. The State agrees to focus on quality of services and accreditation of government facilities.

23. The State/UT agrees to undertake community monitoring on pilot basis,

wherever not tried out as yet, and scale up with suitable model

wherever piloted earlier.

24. The State/UT agrees to undertake continuing medical and continuing

nursing education.

25. The State agrees to make health facilities handling JSY, women andchild friendly to ensure that women and new born children stay in the


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facility for 48 hours.

26. The State Governments shall, within 45 days of the issue of the Recordof proceedings, issue detailed District wise approvals and place them on

their website for public information.27. The State agrees to return unspent balance against specific releases

made in 2005-06, if any.28. The State is entitled to engage a second ANM to the extent that it

provides for MPW (Male) or the contractual amount of 2 nd ANM be paid

out of State Budget and Third functionary may be engaged from NRHM

Fund.


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IV - BROAD FRAMEWORK FOR

PREPARATION OF PIP 2010-

2011


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Broad framework for Preparation of State PIPs

2010-11

Background

The Planning process under NRHM has seen significant evolutionfrom norm based funding in 2005-06 under NRHM to a bottom upprocess resulting in 617/643 Integrated District Health Action Plansfor the country in 2009-10. The District Plan as the key instrument of planning has contributed significantly to the considerableachievement of NRHM in a short span of 5 years. Its contribution insetting up of enabling institutional structures right from the village tothe State level , provision of untied resources for local action,identifying areas for focused attention through facility and householdsurveys, convergence with wider determinants , have been some of the many achievements of decentralised planning. The BroadFramework for preparation of District Health Action Plans, issued inAugust 2006 by the Ministry of health and Family Welfare, has beenthe basis for planning under NRHM. It laid down a comprehensivestructure for the planning process and all programme divisionsprovided the basic formats within which information was required forthe effective planning and implementation of NRHM. The broadcontours of the District Health Action Plan, resource allocation and

norms, system of conducting situation analysis, Block levelconsultations, setting objectives, district planning workshop, workplan and average costs, monitoring and programme managementand the structure of the District Health Action Plan, were discussed ingreat detail in the Broad planning framework for NRHM. This hasformed the basis for decentralized planning.

The initial journey of resource and input intensive planning hasbeen essential to galvanise a hitherto underfunded andunderperforming, public health system . The provision of resourceshas led to expansion of public health infrastructure, additional humanresources, and creation of community structures for greatercommunity ownership. This strong push to system strengthening, in adecentralised and non verticalised framework has also had positiveprogrammatic impact evident in increased access to public healthsystems, evident in increased number of OPD, IPD cases,immunisation, institutional delivery, reduction in disease relatedmorbidities etc.

However, now as NRHM enters mid course, focus onconsolidation, accelerated pace of implementation for fasterachievement of health outcomes becomes imperative. In its fiveyears course, a lot of evidence both from primary ( household andfacility survey, community monitoring reports, internal HMIS data etc


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) and secondary sources (DLHS-III, SRS, Common/ Joint ReviewMission, Independent Survey and Evaluations etc ) have thrown upnewer challenges which need to become the base for a newerevidence based planning.

S ituational Analysis

The current situation regarding health status, health services, humanresources in health, access and utilisation of services, should beanalysed using all available data sources.

Possible Data Sources:

TrendsNFHS, DLHS, SRS, Census

Current situation IDSP, HMIS/DHIS, NRHM quarterly reportingOthers--Facility surveys, micro-studies, programme evaluationsQualitative assessmentsCRM, Community monitoring

Triangulating data sets gives reliability to the situational analysis.Bringing together the analytical findings of these data sets into alogical coherence provides additional and important insights onachievements as well as gaps.

Para on the possible use of each one and how they can be analysedtogether given in the appendix.

Need Assessment

Based on the situational analysis and broad goals and objectives of NRHM, priority areas have to be identified for action in the comingyear. Achievements as well as barriers to operationalisation of plansshould be identified and taken into consideration. Adopting thestrategies laid out in the NRHM framework for action, activities shouldbe planned along with ways of overcoming the barriers to theiroperationalisation experienced in the past.

Incremental systems strengthening is a primary goal and requiresassessment of the stage reached by the State/district/block in variouscomponentsinfrastructure, human resources recruitment andtrainings, services provided, ..

Operationalising the System for Health Outcomes :

Since we are 4 years into the NRHM, it can be expected that we focuson some health outcomes as well. While IMR and MMR require longerperiods for impact and measurement, and have multipledeterminants, outcomes contributing towards the lowering of theseindicators, can be planned for within one year. For instance, if water-


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borne diseases such as diarhoeal disease and jaundice may beidentified as major health problems in a district, using IDSP data orblock level ANM/MO assessment. [We could think of ASHAs collectingmorbidity data for their village and that would help identify priorityproblems and hotspots within a block or even as tolas within avillage.]Strategies & Activities

Besides planning for all the NRHM strategies, planning for control of the identified priority problem could be done with intensive input.

This would require emphasis on convergent planning with waterdepartment, TSC, ANM/MPW (M), AWW and ASHA. Similarly, if malnutrition in children is identified as the problem, suitable planningwould have to be done to target it. For MMR, PNC is a commonlyfound lacuna and this could be identified as priority.

Each state should identify 1-3 such problems and thestrategies/activities they will undertake, with the expected outcomeby the next year. The outcome could be decreasing the hotspots orthe incidence in these areas. This would be taken as a non-negotiableoutcome for the state. [While initially, low levels of outcome may beaccepted, the scale of outcomes should rise substantially in thecoming year, especially in states where institutional strengtheninghas proceeded well.]

For the states/districts which have reached a substantial level of

strengthening of infrastructure, HR and management structures,outcomes in terms of meeting the full spectrum of service deliveryguarantees must now be insisted upon. Operationalising the systemfor horizontally and vertically integrated outputs for achievingspecified health outcomes is now the requirement.

Where capacities are still weak to do so, prioritization of 1 or 2problems and outcomes against those will give a push to thestrengthening process.

For Targetted, Context-specific, Non-negotiable Outcomes

BLOCK level

A. Each block prepares a SC level plan for delivery of service guarantees to each of the villages under itscharge.

B. In addition to existing activities, dealing intensivelywith one major childhood health problem to contribute todecline in mortality:


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Each block to identify major public health problem (eg.diarrgoel disease, malnutrition, malaria) contributing to childmorbidity and mortality and ensure services for it.

Identify hotspots (villages or tolas within villages) using IDSP,MO/ANM/ASHA information and plan intensive convergentinputs for them.

Organise use of STGsas a home to hospital continuum.

State the committed outputs/outcomes

DISTRICT level

A. Triangulation of data:

IDSP, HMIS/DHIS to give current data (NRHM concurrentevaluation in 284 districts to be used when available)

SRS, DLHS & NFHS to identify trends

Any other: facility surveys/ ICDS-ANM data on weight of children/collation of block data/ micro-studies etc .

B. Facilitation and supportive supervision of block exercise to ensure basic service guarantees. HR andtrainings to be planned accordingly.

C. Facilitate block exercise at identifying major healthproblems and dealing with them.

D. Train and supervise use of STGs for at least the

identified major problem.

STATE Level:

A. Develop STGs (Standard Treatment Guidelines) fromhome to hospital continuum: for child health + 1 major adulthealth problem other than the NHPs.Plan all inputs to fulfillthese in addition to existing programmes, as systemstrengthening activities. For instance:

Diarhoeal diseaseHBNCC + rehyderation at all 24x7PHCs + convergent inputs


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MHplan for increase in PNC

Malnutritionstrengthen VHSCs and VHNDs to identifymod-severe malnourished children (hotspots?)link AWW-ASHA-ANM & SHGimprove child care and feeding in thevillage as a whole.


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B. Ensure HR in place and trainings

Log-frame given below may be useful for the Planning

For Block level: Collating data from each village by SC staff

Sl.No

.

Issues in Planningfor SDHs/ DHs

CurrentStatus

Activities tobe

undertakento achieve

targets

Outputs tobe achieved

TimeFrame

for 2010-11

Delivery of serviceguarantees ineach village

HMIS/DHISdata, PHC &ANM service-mappingexercise(toolkit inappendix)

Identify (i) onemajor childhoodhealth problemand its hotspots.

IDSP, PHC &ANM healthproblems-mapping(toolkit inappendix)

Plan to undertake

intensiveconvergent actionfor its prevention,especially in thehotspots.Put in use STGs todeal with patients.

For District level facilitation and supportive supervision of targeted context-specific outcome

Sl.No

.

Issues inPlanning

Current Statusas per evidence

from datatriangulation

Activities tobe


targets

Outputs tobe

achieved

TimeFrame

for 2010-11

I. Facilitationand

supportivesupervision of

Triangulatelarger data sets

with block leveldata on

HR andtrainings to

be plannedaccordingly.


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a)

b)

block exerciseto ensurebasic serviceguarantees.Ensure HR /skills/Supportivesupervision

HR/skills/services

Protocols forsupportivesupervision

II. Facilitateblock exerciseat identifyingmajor healthproblems anddealing withthem.

Collate blocklevel data onchildhood healthproblems and itshotspots.

Triangulate withother sources of data on healthproblems (IDSP,SRS onIMR/MMR,

III. Orient andsupervise useof STGs for at

least theidentifiedmajorproblem.

a) Trainingfor use of STGs for at

least theidentifiedmajorproblem.b)Preparation of supervisoryprotocol foruse of STGs

IV.

a)

b)

Facilitateintensiveconvergentaction forpreventiveaction.Activeinvolvementthrough DHS of members from

all concerneddepartments/P


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RI.Strengtheningof VHSCfunctioning.

In an effort to facilitate evidence based planning based on datatriangulation, the present framework for 2010-2011 has beenprepared by the Ministry to help in the process of planning focusingon deliverables and key health outcomes. The focus here is tofacilitate in achievement of Timelines and Programmatic Targets of NRHM to impact on key health indicators. Therefore it is proposed toaccord approval of Annual Plans on the basis of a log frame in the PIPwith the States stating quantifiable targets which would then bemonitored not only nationally but also at the state / district andbelow level.


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V INSTITUTION SPECIFICNRHM WISE DATA NEEDS

(PART B AND E OF PIP)


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V - INSTITUTION SPECIFIC NRHM DATA NEEDS

INSTITUTION SPECIFIC TIMELINE TARGETS AIMED ATINSTITUTIONAL STRENGTHENING/SERVICE GUARANTEES

Some of the specific targets against various activities of NRHM are asfollows:

1. ASHA: Around 7.30 lakh ASHAs have been selected and areactively engaged in bringing health to the community. However theissue of selection which was primary at the beginning of NRHM hasnow settled down in most states throwing up newer issues with clearimpact on quality of services being provided by her relating to :

Streamlining delay in payment of performance incentives to

ASHAs.Regular upgradation of skill / completion of 5th Module

training The timely and sustainable availability of drug kitsSupervisory structure for ASHAs

Therefore this years PIPs would require a logframe, on themilestones to be achieved in putting in place robust ASHA system onthe above issues. The PIP would require to mention the activitiesproposed to be taken to achieve the above milestones within a

timeline which may be specified by the State.ASHA Timeline: As per timeline for NRHM activities, 100%fully trained ASHAs with drug kits available for every 1000population/large isolated habitation by 2008

Sl.No.

Issues inPlanning in

ASHA

Current Statusas per

evidence fromdata

triangulation

Activitiesto be

undertaken to

achievetargets

Outputs tobe

achieved

TimeFrame for

2010-11

2. Village Health and Sanitation Committee: The VH&SC as thepivot of Village level Planning has been constituted in almost all theStates except a few. The issues which require a deeper look in termsof Planning are namely as follows:


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A. The constitution of the Village Health and SanitationCommitteeB. The capacity of the PRIs in Village Level PlanningC. Utilisation of the Untied fund for the VH&SC and purpose for

which they are utilizedD. The training sessions held for PRIs

VH&SC Timeline: As per timeline for NRHM activities, 100%VH&SC constituted in over 6 lakhs villages and untied grantsprovided to them by 2008

Sl.No

.

Issues inPlanning forVH&SC

Current Statusas perevidence fromdata

triangulation

Activities tobeundertakento achieve

targets


TimeFramefor 2010-11

3. Rogi kalyan Smaitis : The Rogi Kalyan Samiti as the pivot of facility based planning and community involvement and ownership of the health facilities has by and large been constituted in all States.RKSs have contributed to local level leadership and need based

decision making. The issues which now need to find a reflection inplanning would interalia relate to:

Performance and pace of utilisation of funds and Activities being under taken by RKS

RKS Timeline: As per timeline for NRHM activities, 100% RKSconstituted in all CHCs, Sub District Hospital/ DistrictHospitals by 2009

Sl.No. Issues inPlanning forRKS

Current Statusas perevidence from

datatriangulation

Activities tobeundertakento achieve

targets

Outputs tobe achieved TimeFramefor 2010-

11

4. Sub Centre : The Subcentre as the first facility interface of community with a health facility under NRHM is the key to improving


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access and reach to the remotest and the underserved areas.Although construction / upgradation and placement of ANMs atSubcentres have expanded outreach, issues relating to shortfall of ANM due to non availability of ANM, consolidation of SCs beforefurther expansion are some issues which need closer deliberation inthe Plans of 2010-11. Full justification for expansion needs to beprovided if consolidation of available infrastructure has not beenachieved. Need based expansion clearly articulating the area of requirement needs to be highlighted with a clear human resourceplacement plan. The number Sub-Centres already upgraded andunderway and number of sub-centres proposed to be taken up shouldbe spelled out.

The issues which have been highlighted with regard to sub centrestrengthening

a. Construction of subcentres without human resourcedeployment

b. Pace of Utilization of untied fund, annual maintenancegrant( only for subcntres in own/government building)

c. Shortage of ANMsd. Placement of Male Multi Purpose Worker / 2 nd ANM

Sub Centre Timelines: As per timeline for NRHM activities,100%, 2 ANM Sub Health Centres strengthened / establishedto provide service guarantees as per IPHS in 1,75000 places

by 2010

Sl.No

.

Issues inPlanning for Sub

centres

CurrentStatus as per

evidencefrom data

triangulation

Activities tobe


targets


TimeFrame

for 2010-11

5. Primary Health Centre: The PHCs as the first interface of amedical officer with the community has seen considerable progressunder NRHM with many health facilities delivering 24X7 services andpositioning of 3 staff nurses under NRHM. However issues which need

focus in the current plan relate to:


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1. Placement of human resources esp nurses to ensure 24X7services

2. feasibility of ensuring 24X 7 services in all the extant PHCs-redefining the numbers as per evidence and need

3. Consolidating 24X7 PHC s in identified PHCs before furtherexpansion

4. Quality of care being provided in the PHCs5. Parameters for monitoring service delivery and quality of care

at the PHCs6. Pace of utilisation of untied funds , AMG grants in PHCs,

functioning of Rogi Kalyan Samittees

In case of PHC, CHC, District and Sub-District Hospital they should provide information on number of units taken up for upgraded completed, work construction and now provided to be taken up.

PHC Timelines: As per timeline for NRHM activities, 100%,Primary Health Centres strengthened / established to provideservice guarantees as per IPHS in 30,000 places by 2010

Sl.No

.

Issues inPlanning for

PHCs


evidencefrom data

triangulation

Activities tobe


targets


TimeFrame

for 2010-11

6. Community Health Centre: The Community Health Centre withthe first provision for specialist support and as the First Referral Unithas witnessed considerable expansion under NRHM. However issuesrelating to

Acute shortage of Specialist and Nurses norm may have tobe revisited to make it realistic

Blood storage units operational in 9.2 % of facility- need to beensured in all facilities.

Performance parameters for service delivery and quality of care needs further improvement and closer monitoring

Use of untied funds , AMG grants in CHCs, functioning of RogiKalyan Samittees

CHC Timelines: As per timeline for NRHM activities, 100%,Community Health Centres strengthened / established to


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provide service guarantees as per IPHS in 6,500 places by2010

Sl.No

.

Issues inPlanning for

CHCs


evidencefrom data

triangulation

Activities tobe


targets


TimeFrame

for 2010-11

7. Sub District Hospitals/ District Hospitals: The Mission has led

to increase in the number of Sub District Hospitals and DistrictHospitals functioning as 24X 7 facilities and as FRUs. Observationalstudies have also reported increase in OPD and IPD and bedoccupancy. However issues that remain unresolved are:

1. Limited managerial capacities to manage health facilities2. Infrastructure expansion without requisite human resource,

equipments supplementation3. Deployment of human resources not based on need.

Suboptimal or over utilisation of the manpower4. Limited capacity for supply chain management to ensure

timely supply of drugs and diagnostics5. Limited referral and mobility arrangements6. Varied use of RKS , AMG and Untied Funds made available7. Non standardised treatment protocols leading to adhoc in care8. Inadequate PPP arrangements with the private sector in the

area

Sub Distirct/ District Hospital Timelines: As per timeline forNRHM activities, 100%, Sub District Hospital (1800)/ DistrictHospital (600) strengthened to provide quality services by2010

Sl.No.

Issues inPlanning forSDHs/ DHs

Current Statusas per

evidence fromdata

triangulation

Activities tobe


targets


TimeFrame

for 2010-11


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8.Mobile Medical Units: The provision of MMUs in hard to reachareas has greatly expanded the reach of NRHM in the hithertounderserved areas. Apart form the mandatory 354 MMUs in 643districts as per the mandatory timeline, there are many block / villagelevel Mobile Medical Units being provided in many States. Statespecific requirement of MMUs needs to be assessed realistically. NGO/ GPS based system with performance monitoring has been found tobe superior than direct implementation arrangements. However theefficacy of the MMUs depend on the output being delivered by MMUsin terms of performance.

Performance parameters which help in gauging performance of MMUslike, a)Frequency of Visit b)Following of Schedule c) AdvanceIntimation of Schedule d) Duration of Stay and Timing of MMUe)Doctors accompanying f)Availability of Medicine g)Cured of illnessin last visit h)People satisfaction about skill and behaviour i)Locationof MMU j)Average distance travelled to MMU k)average time takenper patient l)Availability of diagnostics m)Follow up of Patients, needto be reflected in the MMU plan

MMU Timeline: As per timeline for NRHM activities, 100%MMUs provided to each district of the country by 2009

Sl.No.

Issues in MMUs CurrentStatus as per

evidencefrom data

triangulation

No. of MMUs

Activities tobe

undertakento achievetargets No.

of camp held

Outputs tobe

achieved

TimeFrame

for 2010-11

9. District Health Action Plans: The DHAP is the key instrument in

decentralised planning. It is observed that in 617 out of 643 districts,District Health Action Plan have been prepared. However theendeavour in 2010-11 should be that DHAPs should not remain astatement of intent but capacity for more evidence based planningbased on data analysis and identification of gaps needs to bestrengthened. Therefore it is important that the district planningexercise is closely hand held , and implementation of works inaccordance with IDHAP. A monitoring protocol to capture theprogress of District Plan needs to be finalized by the State andappended to the State PIP and a Quarerly, Distirct wise progressreport on the monitoring indicators be maintained at the State levelfor supportive supervision and feedback.


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Suggested Monitoring Protocol for the District Action Plansfor NRHM Part B of PIP

Sl.No

.

Activity/Process Indicator CurrentStatus

Target for2009-10asproposedby theDistrict

OutcomeMonitoring

1 ASHAA ASHAs trained in 5 th ModuleB ASHA provided with drug kitsC Avg. time taken for ASHA

payment2 Village Health and Sanitation

CommitteeA No. of Village Health andSanitation Committeeconstituted

B % Untied Grants utilised byVH&SC

C No of training sessions held forPRIs at Village Level

3. Rogi Kalyan SamitteesA No. of Rogi Kalyan constitutedB % Fund utilised by Rogi Kalyan

SamitteesC No of RKS meetings held4 Status of Health Infrastructure

No. of Subcentres functioning inown buildingNo of Subcentres proposed forconstructionNo of Subcentres proposed forupgradationNo of PHCs where facility survey

completedNo of PHCs proposed forconstructionNo of PHCs taken forupgradationNo of PHCs conducting at least10 deliveries per dayNo of CHCs where facility surveycompletedNo of CHCs proposed forconstructionNo of CHCs taken for


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upgradationNo of CHCs conductingcaesarean sectionNo. of CHCs with blood storageunitsNo of District Hospitals wherefacility survey completedNo of District Hospital taken upfor ConstructionNo of District Hospital taken upfor Upgradation

5 Status of Human ResourcesNo of Subcentres without ANMNo of Subcentres without 2ndANM

No of PHCs without 3 staff nursesNo of CHCs withoutAnaesthetistsNo of CHCs without Obstetricand GynaecologistsNo of CHCs without Paediatrician

10. Activities taken up with support under other programmes

such as Donor Partners, Minority Development, Finance

Commission Award, Labour, DONER and any other scheme

etc. to be clearly reflected in Part B of PIP. Similarly details of

PPP activities, Health Insurance scheme and any other district

innovation funds being solicited, details need to be spelt out in

Part B.

11. Intersectoral Convergence activities with line Departments to be

specified in written part E of PIP including with PRI, ICDS, Rural

Development, PHED, Education, Labour, Home etc. Similarly

details of Ayush activities to be also given in Part E .


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Road map for Infrastructure and Human Resource

Strengthening for 2010-11

NRHM has led to considerable expansion of infrastructure in ruralareas and many more health facilities are now functioning 24X7 andFRUs due to provision of extra resources from NRHM. However thetime to take stock has come. It is presumed that all infrastructureproposals, both for new construction and expansion are based onboth facility and area mapping exercise and are not just a districtwise allocation exercise. The needs of the underserved areas have tobe taken into consideration and strengthening of facilities in closecontiguity needs to be discouraged unless justified by a heavy caseload. The IPHS norms are under revision. Therefore the focus shouldbe on consolidation and need based expansion supplemented with aHR plan.

NRHM has led to provision of considerable contractual humanresources at all levels based on local criteria. However the followingissues in provision of human resources continue to need attention

1. Provision of human resource based on gap analysis with adequate /incentivised provision for difficult and hard to reach areas.

2. Capacity and skill development of the human resource bothcontractual and permanent.3. Filling up of existing vacancies by the State Government.

Therefore it is proposed that the planning exercise of 2010-11should reflect gaps in human resources and the effort of the State tofill it in the following format with clear road map on filling up of existing vacancies by the State Government if achievement of IPHSstandards may seem a bit too remote and are under revision.

Infrastructure Health Status (District Wise position to be alsoattached as Annexure)

State Requirement of Infrastructure DH /SDH

CHC

PHC

SHC

Required as per IPHS

Existing Facilities

Shortfall against required as per IPHS


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Mapping of facilities undertaken

Requirement of new facilities after mappingexercise

Requirement of facility upgradation after mappingexercise

Facilities already being undertaken under NRHMfor strengthening

New construction proposed under NRHM after gapanalysis for 2010-11

Facilities proposed for up gradation after gap

analysis for 2010-11

Human Resource Health Status (District Wise position to be alsoattached as Annexure)

State Requirementof HR

Doctors

Nurses

ANMs

Pharmacists

Lab tech

Required as per IPHS

Required staff as perIPHS for the existingfacilities

Sanctioned staff

In Position

Vacancy againstsanctioned

Vacancy against IPHS

Vacancies already filledup by the State

Proposed filling up of vacancies by the Statefor 2010-11

Contractualengagement through

NRHM


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Contractualengagement proposedunder NRHM for 2010-11


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NATIONAL RURAL HEALTH MISSION

Budget Format for NRHM Mission Flexible Pool Part B * and Part E

S.No. Initiative

NumberProposed

RateProposed

TotalAmount

(inlakhs)

Remarks

A ASHAsA1 Selection & Training of ASHAA2 ASHA KitA3 ASHA IncentivesA4 Others

TOTALB Infrastructure related matters

B1 New Construction of DH

B2 Renovation / Upgradation of DH B3 New Construction of CHCs B4 Renovation / Upgradation of CHCs B5 New Construction of CHCs B6 New Construction of PHCs B7 Renovation/Upgradation of PHCsB8 New Construction of SCs B9 Renovation/ Upgradation of SC

B10 MMU B11 Emergency & Referral ServicesB12 Any othersB13 Others

TOTAL

C Human Resources relatedmatters

C1 Contractual Specialists C2 Contractual Doctors C3 Contractual paramedical C4 Contractual ANM C5 Others

TOTAL

D Programme Management relatedmatters

D1 State Programme ManagementD2 Divisional PMSUD3 Block PMSUD4 District Health Action PlanD5 Monitoring & EvaluationD6 Others

TOTAL

EUntied Funds, AnnualMaintainence Grants and RKSfundsrelated matters

E1 Rogi Kalyan Samiti- DHE2 Rogi Kalyan Samiti- SDHE3 Rogi Kalyan Samiti- CHCE4 Rogi Kalyan Samiti-PHC/APHCE5 Untied Fund for CHC


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E6 Untied Fund for PHCE7 Untied Fund for SCE8 Untied Fund for VHSCE9 Annual Maintenance Grant -DH

E10 Annual Maintenance Grant -CHCE11 Annual Maintenance Grant -BPHCE12 Annual Maintenance Grant -APHCE13 Annual Maintenance Grant -PHCE14 Annual Maintenance Grant -SCE15 Others

TOTAL

F Training & Capacity Buildingrelated matters

F1 Management Development Trainings

F2 Capacity Building/ OrientationWorkshopsF3 Others

TOTALG Innovations ( No approvalwithout details)

G1 Health MelasG2 District innovationsG3 Incentive SchemeG4 PPP initiativeG5 OthersG6 Health Insurance schemeG7 Others

TOTAL

H Intersectoral Convergence ( Part

E) ( No approval without details)

H1 AyushH2 Intersectoral Convergence RelatedH3 Others

TOTAL

* State may add rows as per need in case specific activity does not find mentionin the format. However, all such rows would need to be as additional rows under

the specific sub head. For example if any row needs to be added under HumanResource it should be termed as ROW C5, C6 etc.

Documents

Guidelines Part 1