NRHM Third Common Review Mission Team Report

1. NRHMThird Common Review Mission Team Report Madhya Pradesh 2009

2. Team Composition Chhindwara team Mr Rajesh Kumar, Deputy Controller General of Accounts, Finance Ministry, Delhi Dr KR Antony, Director-SHRC, Chhattisgarh Ms Mona Gupta, TMSA Guna team Dr Thelma Narayan, Public Health Consultant, CPHE-SOCHARA Mr Sanjeev Gupta, Finance Controller, NRHM Ms Moni Sinha Sagar, USAID

3. Process Visits - Health FaciIities 7 Health Sub Centres ,5 Primary Health Centres 8 Community Health Centres– FRUs, 4 District Hospitals in Guna, Shivpuri, Datia & Chindwara including NRCs & SNCUs Visits - Teaching and Training Institutions 1 each ANM Training Centre, GNM school, Medical College Hospital, Regional Health & FW Training Centre and State Institute of Health Management & Communication, Gwalior Meetings with NGO’s, Psychiatrists & Civil Society groups , Civil Surgeon, CMHO, Dist. Collector Observation- 2 VHSC and VHND Talks with beneficiaries- village markets, roadside & camps

4. What we found…Affirmative Enquiry Strong Political Commitment to Health & good leadership at State level Health Facility Maintenance reasonably good JSY money disbursed promptly Compulsory 2 year rural posting of 255 PG Doctors and 317 MBBS Doctors enforced SNCUs and NRCs are well functioning, clean, with well-trained staff, equipment & supplies in place, Number of ASHAs expanded as per number of Anganwadis

5. What we found…Affirmative Enquiry Mobile Medical Unit - contracted out to NGO adequate staff & medicines, regular Janani Express – plying, available on mobile call, operating efficiently Call center at Guna- coordinates vehicles for deliveries & emergencies, cost effective: should be scaled up. Good donor coordination -VHSC training, SNCU/NRC under UNICEF program, SBA training by UNFPA, JICA promoting MCH service, MPTAST for planning, staff recruitment etc

6. What we found…Affirmative Enquiry District Health Society meetings - regular District level IEC planning being attempted: inter-sectoral convergence through BCC cell at Guna Focused communication efforts undertaken based on Behavioral Determinant study done by UNICEF in Guna RKS fund well utilized in the District hospital-Chhindwara for diagnostics, construction, repair – generating more money through renting out shops Guna- deliveries at the sub-center level- reducing load in the district hospital

7. What we foundFinancial Management Fund flow efficient at all levels, accounts compiled on Tally e-transfers + sanction letters are e-mailed from State to Districts. Financial approvals of DAPs & delegation of Financial & Administrative powers have been communicated to Districts. Post of JD-Finance created to provide leadership to F&A staff Concurrent audit -completed till March 2009 - a major factor in improved quality of accounts keeping at lower levels

8. What can be improved - Challenges HRH – teaching & CE: SIHMC Gwalior is underutilized & needs upgradation, RHFWTC- to do higher level trainings. ANM /GNM training centers understaffed, need substantial infrastructure improvements ANMs need skill up-gradation for quality ANC, midwifery & PNC Support for PMUs to be improved- for BPMU by DPMUs and SPMU High staff turnover in DPMU Supportive supervision of ASHAs lacking

9. What can be Improved - Challenges Lack of IPC materials for grassroots level workers FP counseling in post partum period not adequately done – huge opportunity under JSY being lost. Community monitoring- findings not shared with all staff- feedback not effectively utilized, expansion from pilot not done More inter-sectoral linkages needed with Dept. of RD for safe drinking water & sanitation, and Women and Child Development for Nutrition

10. What can be improved - Challenges Decentralization for IEC planning has happened without any capacity building and monitoring against the district IEC plans not being done Annual Maintenance Grant and Untied Grant not part of the RKS: escapes community monitoring. Delegation of F & A Powers need reinforcement: Health Admn. need not depend on Revenue Admn. for routine decisions.

11. What can be Improved-Challenges No segregation of Bio-medical waste at source, waste disposal management poor, staff not trained for it. No display of available drug stock, drugs expired and buried inviting media criticism Emergency management- not organized, staff not trained, drugs not easily accessible Doctor absenteeism pointed out by media Districts & institutions not visited reportedly are worse in terms of quality of care and access to care

12. What can be improved - Challenges A surprise night visit to Pipariya CHC (Hoshangabad) showed absolute lack of cleanliness despite 3 Sweepers + 4 on contract from NRHM - darkness in common areas, no bed sheets and patient amenities, poor waste management, problems associated with home clinics of docs in hospital premises. RKS funds and AMG and UG almost fully utilized. “Money spent alone cannot be a yardstick to measure patient welfare or fulfillment of RKS objectives”.

13. Recommendations National level meetings of SPMs and State level meetings of DPMs needed All States may put RKS fund utilization under public domain and start monitoring it through a process of social audit. Display of essential drug stock on the walls of health facility Expansion of Community Monitoring & Planning from pilot districts to rest of the state in a planned manner with budgetary allocation

14. Recommendations ASHA support structure & ASHA resource center to be set-up & strengthened ASHA selection and deployment: the norm of same village candidate and not related to any government staff is to be followed, dropouts to be replaced & trained ASHA training to be completed as per norms Strengthen community action for Nutrition - train ASHAs on nutrition & new born care

15. Recommendations Link training institutes at different levels and ensure good quality training Comprehensive integrated CME & training plan should be developed by SIHMC Develop a public health training institute in the state Post-SBA in-service training & handholding for ANM/Mos. A Helpline ? Staff competence & motivation to get high priority

16. Recommendations ANM training manuals & teaching process done by JICA may be used state-wide Emphasis on family planning, specially spacing methods, needs to be increased IEC bureau infrastructure and staffing needs to be strengthened for BCC & health promotion IPC tools, job aides for ASHAs/ANMs needs to be prepared at the state level & training given for their use

17. Recommendations TB (RNTCP) & leprosy component to be strengthened – with district level staff, more Lab technicians and community involvement through VHSCs & ASHAs Mental Health care to be strengthened with District Mental Health Program Timely promotion to boost staff morale Untied Funds & Annual Maintenance Grants to be put under the purview of the RKS which will facilitate wider community participation and Panchayati Raj Institutions may facilitate a social audit.

18. Recommendations Delegation of F & A powers to be reinforced. SPMU and DPMUs to be made common for all components of NRHM. Cash handling to be minimized: Maximum situations to be handled by A/c payee cheques and e-payments. Advance tracking to be strengthened at State and District levels. Channels for reporting back of expenditure from ground level to be strengthened. Concurrent Audit process to be delegated to Districts

19. Thank You For making us part of the common search under NRHM-CRM