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

pdf

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 during
February 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 process
indicators, 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
mission’s 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 April
2005, 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

1
Programme divisions of the MOHFW and were finally appraised and approved by the duly
constituted National Programme Coordination Committee (Chaired by the Additional Secretary,
Ms Jalaja) of the MOHFW.

4. The specific objective of the first review was to assess the progress made on
implementing the shared vision and objectives of the RCH II Programme, with special reference
to areas prioritised for completion in the first year of implementation, as detailed below. (The
Terms of Reference for the JRM are attached as Annex 1)

Governance and Programme Management- issues related to setting up the agreed

Programme Management structures at the State and the districts (SPMUs and
DPMUs) delegation of responsibilities, integration of societies, and convergence with
other departments.
Financial management -Issues related to allocation of the funds to the districts, status
of FMR, UCs, progress on disbursements and expenditures.
Strategies for improvement of maternal health, including contraception, adolescent
and child health by providing quality services for meeting unmet demands - issues
related to identification of facilities for provision of 24-hour services, upgrading
CHCs to IPHS standards, human resources need for provision of services, progress
on operationalisation of FRUs, implementing IMNCI promoting male participation
(NSV), & bringing about behavioural changes through advocacy/IEC/Training.
Innovations - issues on PPPs, i.e. contracting the NGOs or private sector providers
for provision of RCH services; demand side financing.
Equity and access- strategies to identify and better serve the vulnerable and the under
served population groups such as SC/ST and urban poor; community participation
and gender mainstreaming, BCC initiatives.
Intersectoral convergence of RCH with Disease Control programmes & HIV /
AIDS/ICDS/Sanitation/DW
Monitoring and Evaluation, including the move to focus on results, triangulation.

Overview of Progress to Date

5. The NRHM launched by the GOI in April 2005, aims to improve the health status of the
rural poor through promoting convergence of RCH II and infectious diseases Programmes with
water and sanitation, Panchayati Raj & rural development, and women & child welfare
Programmes at district level. The RCH II is a critical component of the NRHM. The NRHM
promotes participatory planning with flexible budgets that are responsive to the health needs of
the communities and districts. The NRHM also envisages the active participation of the
Panchayat Raj Institutions and civil society groups in evolving the district and village health
plans, which can further strengthen the community needs assessment under the RCH Programme.

6. The MOHFW has appraised and approved all 35 State /UT RCH II PIPs for the year
2005-06 and funds have been released as per the approved PIP. The MOHFW approved the state
RCH II PIPs for Rs 1523.75 crore and released Rs. 730.54 crore to date.

2
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 been
conducted 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 Support
Units and, to varying degrees, contracted management support staff, including Chartered
Accountants, 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 as
Rajasthan, 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 Kalyan
Samities 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 State
review sheets.

12. As internationally acknowledged and reflected in the national PIP for RCH, a well
functioning 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 MOHFW
has 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 the
Programme. The MOHFW has prepared a reporting format under the framework of NRHM, and

3
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 their
training 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 to
increase 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 sector
is 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 sector
since 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 accelerate
implementation 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 with
the 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 under
NRHM (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 State
visits to Assam and Chattisgarh, and other States also reported this.

20. The biggest challenge observed is the limited capacity to manage such a comprehensive
and 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

4
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 of
Manipur, 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 & Sikkim
have 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 the
remaining 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 by
the States. However the understanding needs to be translated into action in the preparation of
DAPs. 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 the
DHs 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, the
operationalisation 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

5
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 the
flexible 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 considerably
reduced the lag in delay in release of funds post approval. The releases are now reaching
States/UTs within 24–48 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 which
action 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 and
Districts 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 be
better 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 by
the 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 in
order 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 not
agreeable with the combined budget head.

6
c) The Ministry may prepare a six monthly report on the financial progress of activities
implemented 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 the
States that UCs, even if provisional, may be submitted immediately after the close of the
financial 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 as
repair/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 the
following 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 level
of compliance by districts needs to be ensured by the States.
The basis of reporting expenditure by States and consistency across States/ districts needs
to 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 the
consultants are utilized effectively.
• State level society mechanism is still being predominantly used for maintaining bank
account 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 management
costs. 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 reporting
of 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 plan
would 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

7
30. Universal access to skilled attendance at birth and increasing access to quality emergency
obstetric 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 have
been 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 progress
in 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 components
concurrently, 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 contractual

appointments. 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 reach
vulnerable/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-saving
anaesthetic 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 will
be 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.

8
34. Guidelines for antenatal care and Skilled Attendance at Birth, and Management of
common 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 of
training 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, Rajasthan
and 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 States
due 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 of
accelerating 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, due
emphasis 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.

9
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 the
MYP in varying degrees. While there have been good initiatives on micro-planning and
introduction 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 guidelines
accordingly. 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 Court’s 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 SOPs
for 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 over
the 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

10
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. GOI
is 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 for
accreditation 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. The
MOHFW 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 of
the 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 the
training 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 these
trainees.

Adolescent Reproductive Health

45. A National Consultation on RCH II ARSH Strategy: Development of National
Operational 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

11
46. Pilot PPP interventions have to be prioritised for districts with higher vulnerable
populations, 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 implementing
innovative actions including partnerships with NGOs and the private sector to improve the use of
RCH 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 Sanjivani
Yojana 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 on
services 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, Vit
A, neo-natal care, FP, safe motherhood)
Jhakhand - Detailed strategy developed for block level planning for tribal health
care
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) health
insurance for SC/ST population
Haryana – (i) use of delivery huts; (ii) quarterly state review with district
magistrates 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

12
48. If the goals of RCH II are to be achieved each State needs to undertake a Situation
Analysis 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. This
will 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 November
2005, 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 evolved
after 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 under
NRHM. 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 close
coordination. 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

13
panchayat, women’s 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 the
MNGO scheme and had not completed the selection of MNGOs/ FNGOs. This should be
addressed 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 NACO
need 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 following
major 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 to
the 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 State
Demographers/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 two
rounds 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 Gujarat

and 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.

14
60. On the evaluation front, the DLHS II reports were finalized and activities on DLHS III
have 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 policy
to 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 for
developing 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 enhancing
management 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 inputs
for making necessary changes in the Programme if needed.

65. Training division in MOHFW and training cells in the states need to be strengthened for
steering 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 to
branding 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) are
published 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 per
earlier plans without any comprehensive BCC strategy. States will need support for developing
and implementing a decentralized BCC strategy.

15
68. National level mass media activities will have to be supported with inter personal and
group 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 clearly
identified 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 Partners
to 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 since
November 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 systems

72. A hub and spoke arrangement allows for a team of experts to be based in Guwahati and
provide 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

16
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 State
PIP. 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 Reviews
Governance / Programme management
The MOHFW to finalise the NRHM implementation framework and provide details
on 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 in
the 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 that
resources can be appropriately allocated to the most needy areas
A Joint Secretary has been appointed at central level to assist all the high focus
States 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 States

Financial 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

17
Technical Interventions
The need for any new construction should be justified. States should first focus on
making 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 implementation
of 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 identifying
incentives 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 and
training 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 vis
activities planned under District Action Plan (DAP).
2. District lacks capacity to prepare DAP’s, 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 be
considered 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 / UT’s complete their preparation,
appraisal and approval of DAP’s within six months. The support from all the
development partners, International agencies and MNGO’s may be visualized for
completing the task.
5. The M&E division of the Ministry will ensure that the complete information as per the
two rounds of Rapid Household Surveys (RHS) surveys on all the Districts will be made
available to all the States/ UT’s. This is to provide sufficient baseline information to
prepare DAP’s.
6. The Ministry requested all the States and UT’s to prepare a comprehensive training plan
including all the training components from all the interventions such as CH, MH, IEC
etc…Also 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 other
contractual Medical Specialist, vacancies by September 2006.

18
8. The Ministry may establish on line help line to provide assistance in program
management to all the States and UT’s 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 District
Hospital to make it completely functional.
• States need to prioritize the IMNCI strategy for implementation with thrust at
community level which may be adequately be addressed in the RCH II PIP.
• States need to assess their management requirement at Block level, which need to
be addressed in RCH II PIP.
• MOU need to incorporate related provisions to ensure the establishment and
functioning of PMU’s at both the State and District level.

19
 Priority Actions
(March 2006-January 2007)
Responsible body Time frame
Issue Actions
Governance/
Finalise the NRHM implementation
Programme MOHFW 31 March 06
framework and clarify the procedures and
management/
regulations in order to ensure that there will
convergence
be the desired convergence by 2007.
Fill the remaining positions stipulated in the States / districts 31 March 06
PIPs for the SPMUs and DPMUs, and
complete the orientation training
Finalise DAPs so that resources can be
appropriately allocated to the most needy States / districts 31 March 06
areas
Disseminate support team names & contact MOHFW 31 March 06
details to each State
Provide additional funds for RKS if State governments April 2006
necessary, to make them more functional
Address convergence more States / districts July 2006
comprehensively
Though the Ministry mentioned that at the
Financial MOHFW
start of the year, only 1/6th of the proposed
management
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
MOHFW/ States
Provide more clarity on FM procedures at
all levels
States
Provisional UCs to be submitted for 1st year
expenditure for release of 2nd year funds
States
Provide overview of funds allocated,
received, utilised & remaining

Organise TA for select HF states to develop MH Division June 2006

Maternal Health clear plan for making existing facilities
functional, focusing first on those needing
only minimal additional inputs and on those
in the most needy areas

SA of GNM training centres in the States Respective States June 2006

facing shortages for staff nurses and

20
 Responsible body Time frame
Issue Actions
develop a road map

Revision of Drug kits as per new service MH Division March 2006

delivery guidelines

Provide more clarity on the JSY scheme so MH Division March 2006

that available funds are utilised: The FAQ
booklet may be revised & published

Child Health Finalise and dissemination of operational CH Division April 2006

guidelines for IMNCI to be used by the
State and District Programme managers

Develop a strategy for engaging private CH Division June 2006

providers to enable them using IMNCI
protocols

Organise technical assistance to the select CH Division / States June 2006

high focussed States for developing micro-
plans under multi-year immunisation plan.

Family Planning Finalisation and dissemination of manual RSS Division April 2006
for quality assurance in sterilisation.

Develop a SOP manual for RCH camps RSS Division May 2006

Mass-media category promotion for ECPs RSS / IEC Division June 2006

Revision of existing contraceptive service- RSS Division August 2006

delivery guidelines and sterilisation
standards.

ARSH Finalisation and dissemination of IEC Division April 2006

implementation guide for operationalising
ARSH strategy

Finalise training modules for Medical IEC Division April 2006

Officers and ANMs and share with States

Trainings Develop HR policies including training. States August 2006

Comprehensive training plans to be shared States

by the States

Training Division April 2006

21
 Responsible body Time frame
Issue Actions
Assessment of PDC Programme
Training Division June 2006
Commissioning a Situational Assessment
BCC Study of Training Management in health
sector

Develop and dissemination of plans for IEC Division September,

strengthening training management based 2006
on the recommendations of above study

Develop and dissemination of operational IEC Division / States June 2006

guidelines for decentralised BCC strategy
addressing NRHM issues

Organise technical assistance for capacity IEC Division / States July 2006
building of State counterparts to plan,
implement and monitor BCC plans
Innovations Initiate pilots and actions on PPP and other States July 2006
innovations in the State PIPs.
Equity & Situational Analysis On-going
Access/ Map key indicators such as % of MOHFW ,/Chief
Vulnerable underweight children, Institutional Delivery Director, M&E
Groups immunisation (as in RHS), 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. Map
existing 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 States / districts

and PHC, and fully supported by the health
staff at those facilities

Include urban health and tribal health plans States

in the overall PIP so that approval is
obtained simultaneously for all

Document success stories in posting staff to MOHFW/Director,

remote and underserved areas and share Area Projects
with other States

M&E/ focus on Finalization of MIS format from State to M&E Division April 2006
outcomes centre level

22
 Responsible body Time frame
Issue Actions
Preparatory work for piloting of QA. May 2006

Finalization of Programme management July 2006

assessment methodology and manual.

Development of methodologies for March 2007

community monitoring and triangulation of
data
NFHS-III Report, Table, Formats etc. M&E Division April 2006

Completion of Field Work of NFHS-III June 2006

Data entry and Processing Oct 2006

A few summary results, all India level only Nov 2006

National & State Report & Dissemination Start by March

2007

DLHS-III Preparatory work M&E Division May 2006

(Administrative, Technical and
Questionnaire finalisation)

Engagement of Field Organization Aug 2006

Training of Trainers (1st Phase) Sep 2006

Field work – Phase I Oct 2006-Feb

2007

Training of Trainers – 2nd Phase Jan 2007

Field work in remaining districts March 2007-

June 2007

Dissemination of All India Report Nov 2007

Training/ BCC/ Prepare a comprehensive training plan States
NGOs
Others TA – Set up State facilitation teams MOHFW April 2006
(GoI/DP/States) for enhanced support to
EAG & NE States on a continuous basis (till
NHSRC is set up)

23
List of Annexes

I. ToRs of the JRM

II. Process Manual for the State Reviews
III. State sheets on key issues
IV. State PMU matrix
V. Note on Financial Management
VI. Note on e-banking
VII. Field visit reports
VIII. Note on Equity & Access
IX. State support teams
X. List of participants

24