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 aidesfor 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